Health inspection·June 27, 2022

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, a stroke and chronic obstructive pulmonary disease. The resident was dependent on use of an electric wheelchair for mobility after suffering a stroke. Residents Affected - Many On 06/09/22 at 3:16 P.M. Resident #7 was in an electric wheelchair and came up to this surveyor to voice a concern. Resident #7 said the electric wheelchair she was in was one the facility provided for her to use and not the one which had been specifically ordered for her. The resident said her electric wheelchair has been sitting in the smoking room for one and a half years, and the only thing needed to fix it were two batteries. Resident #7 would like to have her own chair back which had been designed for her. Interview with the DON on 06/09/22 at 3:20 P.M. revealed she knew the wheelchair company was in an out of the building a lot lately and she would check on Resident #7's concern. Interview with the DON on 06/13/22 at 12:06 P.M. revealed she was not the one looking into the issue with Resident #7's electric wheelchair as Social Services was following through on the concern. Interview with the Director of Rehabilitation (DoR) #907 on 06/13/22 at 12:20 P.M. revealed she contacted the wheelchair repair company on 06/09/22 after being made aware of Resident #7's concern about her electric wheelchair not being repaired. DoR #907 said the company came to the facility in May 2022 but brought the wrong batteries for the wheelchair. They were supposed to return with the correct batteries and had not yet returned. She was awaiting a return call from the company with an update on the plan for fixing Resident #7's wheelchair. DoR #907 said she has assigned the Physical Therapy Assistant working with the resident to continue to follow up on getting the resident's wheelchair repaired. DoR #907 said she has worked at the facility since November 2021 and does not know why the chair has yet to be repaired. A second interview was conducted with the DoR #907 on 06/13/22 at 2:43 P.M. revealed she had spoken with the repair company's supervisor to find out why Resident #7 has been waiting for her electric wheelchair to be repaired for over a year and requested all documentation be faxed to her regarding the problem. The information had not yet been received. DoR #907 confirmed Resident #7's wheelchair should have been repaired by now. Review of Resident #7's progress notes revealed the facility had been aware of her electric wheelchair not working since 11/15/21 as they had not addressed the authorization dated 07/13/21 filed under the miscellaneous tab in the medical record. Review of the medical record revealed authorization to repair Resident #7's electric wheelchair was provided on 07/13/21. It was filed in the miscellaneous section of the medical record and not addressed by facility staff. This deficiency substantiates Complaint Number OH00132041. Based on review of the resident council meeting minutes and staff interview the facility failed to ensure resident concerns were resolved in an appropriate manner and time frame. This affected five residents (Resident's #7, #27, #37, #66, #73) who resided on the Elmwood unit, 2 Resident's (#40 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 2 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many #72) who resided on the Magnolia unit and had the potential to affect all residents residing in the facility. The facility census was 88. Findings include: 1. Review of the resident council minutes for the 08/30/21 meeting revealed a concern was brought to the attention of the facility regarding nurses being rude to residents and being preoccupied. Review of the resident council follow-up form revealed the action plan revealed no plan in place for the concern. Review of the follow-up form revealed a signature and date provided by the Director of Nursing (DON) on 02/23/22. Review of the resident council minutes for the 09/30/21 meeting revealed a concern was brought to the attention of the facility regarding nurses still being rude to the residents. Review of the minutes revealed no resident council follow-up form. Review of the resident council minutes for the 01/28/22 meeting revealed a concern was brought to the attention of the facility regarding Licensed Practical Nurse (LPN) #873 arguing with residents. Review of the resident council follow-up form revealed the action plan was to speak to LPN #873. Review of the follow-up form revealed a signature and date provided by the DON on 01/28/22. Review of the resident council minutes for the 02/23/22 meeting revealed a concern was brought to the attention of the facility regarding LPN #873 still being rude to residents and always yelling, and State Tested Nurse Assistant (STNA) #868 not doing her job when working on the Magnolia unit. Review of the resident council follow-up form revealed the action plan was to speak to all staff about care and a change would be done. Review of the follow-up form revealed a signature and date provided by the DON on 02/23/22. Review of the resident council minutes for the 03/30/22 meeting revealed a concern was brought to the attention of the facility regarding LPN #873 still yelling and arguing with residents. Review of the resident council follow-up form revealed the action plan revealed no plan in place for the concern. Interview on 06/06/22 at 10:39 A.M. with Resident #84 revealed LPN #873 always yelled at him. Interview on 06/06/22 at 11:23 A.M. with Resident #72 revealed when STNA #868 worked the unit, he waited a long time for care. Resident #72 revealed he had written grievances in the past and nothing changed. Interview on 06/07/22 at 2:11 P.M. during the resident council meeting held by the Ohio Department of Health (ODH) with Resident's #27, #37, #40, #66, and #73 revealed concerns voiced during monthly resident council meetings were not taken care of. Residents revealed staff members were able to continue to be rude due to no disciplinary actions. Residents revealed LPN #873 and STNA #868 continued to be rude to residents despite being reported in the resident council meetings. Interview on 06/08/22 at 10:46 A.M. with Social Services Designee (SSD) #904 revealed any concerns or grievances from residents were placed in a mailbox outside of her office using a designated form. SSD #904 revealed concerns were read through, investigated, and the assigned department worked to get it resolved. SSD #904 revealed any concerns related to her department, she returned it back to Activity Director (AD) #800. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 3 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 06/08/22 at 11:03 A.M. with AD #800 revealed she oversaw resident council, and any complaints were documented on a follow-up form for the department heads to complete and return to her. AD #800 revealed she provided copies of the follow-up form to the designated department head. AD #800 confirmed and was aware of all findings voiced in resident council and revealed she reported all concerns to the Director of Nursing (DON) and the Administrator. AD #800 revealed she had not received any follow-up forms regarding LPN #873 and STNA #868. Interview on 06/08/22 at 2:59 P.M. with STNA #867 revealed STNA #868 can tend to be snippy with residents and not answer call lights. Interview on 06/08/22 at 5:17 P.M. with Resident #40 revealed STNA #868 could be a little snotty occasionally and display an attitude. Interview on 06/09/22 at 8:37 A.M. with the Human Resources Director (HRD) #908 confirmed no disciplinary files for LPN #873 and STNA #868. Interview on 06/09/22 at 1:10 P.M. with the DON revealed after resident council meetings she received a resident council follow-up form, if any nursing concerns were voiced. The DON revealed she acknowledged the form and concerns but did not provide any feedback via the form or return it to the activities department and/or the AD #800. The DON revealed no documented evidence of follow-up to the resident concerns. The DON stated she talked to the staff informally but could not provide any formal documentation. Interview on 06/09/22 at 1:15 P.M. with the Administrator revealed once a concern is voiced during a resident council meeting, it was documented on the resident council follow-up form and provided to the identified department head. The Administrator revealed the form was to be completed and follow-up provided. Review of the personnel files for LPN #873, hire date of 12/29/20, and STNA #868, hire date of 03/30/21, revealed no disciplinary actions. Review of a blank resident council follow-up form revealed a space for the date, department, problem and/or concern, patterns and/or trends, and an action plan, if needed. Review of the form revealed the form was to be returned to the AD #800 upon completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 4 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the physician was notified of physician orders not being followed and significant weight loss occurring for seven residents (Residents #24, #29, #31, #49, #53, #56, and #67) of nine residents on weekly weights. The facility census was 88. Findings Include: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, tremors, psychosis, paranoid personality disorder, and hallucinations. Review of the physician's orders revealed on 06/08/22 the dietician added the nutritional supplement of Ensure Plus to be administered two times a day. On 06/15/22 weekly weights were ordered for Resident #24 Review of the weights for Resident #24 revealed an admission weight obtained on 03/10/22 of 205.8 pounds. His weight on 06/04/22 was 185 pounds indicating a severe weight loss of 10.11% over three months. Weights were obtained on 03/17/22, 04/02/22, 04/03/22, 05/01/22, 05/02/22, 05/05/22, 06/03/22, and 06/04/22. Review of the dietary progress notes for Resident #24 revealed Registered Dietician (RD) #909 revealed the admission assessment was completed on 03/17/22. Resident #24's admission weight was 205.8 pounds and he informed RD #909 his usual body weight was around 205 pounds. RD #909 noted the resident had tremors and had swallowing problems with food, especially if he was eating bread. He also complained of his medications sometimes getting stuck in his throat. Dietary interventions included monitoring weekly weights and discussing swallowing problems with speech therapy. RD #909's next assessment was dated 06/08/22. The resident's current weight was 185 pounds and RD #909 indicated it was a significant weight loss of 10.1% over a three month period. The resident's meal intake was between 51-100% and RD #909 noted the resident does lose food while eating related to tremors. The nutritional interventions implemented were to start Ensure Plus twice a day and obtain weekly weights for the next four weeks. Interview with RD #909 on 06/15/22 at 3:31 P.M. revealed she was aware Resident #24 did not have weekly weights completed as ordered. RD #909 said she tries to find out why the weights were not obtained but was unable to provide a reason for his weights not being completed. RD #909 said she also looks at the resident to see if they look like they are losing weight. The dietician was also unable to explain why she did not reassess the resident after his admission until June. The dietician confirmed she did not refer Resident #24 to therapy to assess if adaptive equipment might enable the resident to lose less food from his utensils when he ate or for them to address his swallowing issues but that it would have been a good idea to do that. RD #909 also confirmed she had not notified the physician of the resident's weight loss as it was not her job to do that. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses including Covid-19, bipolar disorder, Schizophrenia, neuromuscular disorder of the bladder, mild intellectual disabilities, and hypothyroidism. Review of the physician's orders revealed on 05/20/22 weekly weights were ordered. On 05/05/22 a four ounce fortified shake (a nutritional supplement) was ordered for lunch and dinner. Six ounces of fortified juice was ordered to be served with breakfast. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 5 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #29's weights revealed his admission weight was 222.6 pounds and was not obtained until 03/29/22. His next weight was on 04/06/22 and was 217.0 pounds, on 05/04/22 his weight was 209.0 pounds, and then on 06/09/22 his weight was 200.2 pounds. Weights were not obtained per facility policy upon admission and weekly weights were not obtained as ordered on 05/20/22. Review of the admission dietary progress note dated 03/23/22 for Resident #29 revealed RD #909 obtained his admission weight from the transfer papers from the hospital as the facility did not have a current weight for him. RD #909 did not reassess the resident next until 05/05/22 after he was readmitted to the facility after being hospitalized for a change in mental status. Resident #29's diet order was for mechanical soft texture with food to be served in bowls. The resident was readmitted with a Stage 3 pressure ulcer to the sacrum. RD #909 noted Resident #29 drank fluids better than eating the food he was served and that he was pocketing food in his mouth. RD #909 implemented nutritional juice with/ breakfast, a fortified shake with lunch and dinner, and he was to be give Med Pass (a nutritional supplement) four ounces three time a day. RD #909's next assessment dated [DATE] revealed Resident #29 had a significant weight loss of 6.1% since admission. His meal texture was downgraded to pureed foods. He continued to have a Stage 3 pressure ulcer and had also tested positive for Covid-19 on 05/13/22. No new interventions were put in place to prevent further weight loss. Weekly weights were to be obtained once Resident #29 was off quarantine. Review of RD #909 next assessed Resident #29 on 06/09/22. A current weight was not available since he had been identified as a significant weight loss. RD #909 noted the resident looked as if he had lost further weight. RD #909 discontinued the Med Pass supplement and added Ensure Plus twice a day. RD #909 also requested a weight be obtained. RD #909 followed up with Resident #29 on 06/13/22 and a current weight was obtained of 200.2 pounds resulting in a 10.1% weight loss since admission. RD #909 attributed the weight loss to having contracted Covid-19. No further interventions were implemented. Interview with RD #909 on 06/15/22 at 4:00 P.M. revealed she believes Resident #29's weight loss is due to being diagnosed with Covid-19 in May but was unable to explain why the resident had consistently lost weight since admission. RD #909 also did not know if Resident #29 was drinking the supplements she had implemented as the facility does not track how much the resident consumes. The dietician was aware the weekly weights she had ordered were not being done and said she includes that in the dietary recommendations she emails to the Director of Nursing every week after her visits. RD #909 said she thinks the resident does not like the texture of his food and also did not know why he gets round beige lumps with yellow gravy every meal. The dietician said she did not add any new interventions to prevent further weight loss as she believed his appetite would increase now that he no longer has Covid-19. RD #909 confirmed she did not notify the physician of Resident #29's weight loss as it was not her job. 3. Resident #31 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, ventilator dependence, neuromuscular dysfunction of the bladder, shaken infant syndrome, quadriplegia, and seizures. Review of the physician's orders revealed an order was written on 10/20/21 for weekly weights to be obtained for Resident #31. Review of the weights for Resident #31 from February 2022 through the present revealed on 02/08/22 the resident's weight was 112.5 pounds. The next weight obtained for Resident #31 was on 03/29/22 and his weight was 117.2 pounds. The next weight obtained was on 04/19/22 and his weight was 118.1. The last weight available for Resident #31 was obtained on 05/24/22 and was 117 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 6 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Registered Dietician (RD) #909 on 06/15/22 at 4:00 P.M. revealed she was aware the weekly weights she had ordered were not being done. The physician was not notified as it was not her job. 4. Resident #49 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting the left nondominant side after a stroke, high blood pressure, depression, seizures, and morbid (severe) obesity. Review of the physician's orders for Resident #49 revealed on 06/13/22 Ensure Clear (a nutritional supplement) was ordered for three times a day. On 06/14/22 weekly weights were ordered and blood work was ordered for weight loss. Review of Resident #49's weights revealed his admission weight on 01/16/21 was 230.0 pounds. On 12/01/21 the resident's weight was 215.0 pounds. No weights were obtained in either January or February. The next weight the facility obtained was on 03/03/22 at 176.5 pounds. No reweight was obtained. The next weight available was 04/05/22 and was 197.0 pounds. No reweight was obtained. No May weight was obtained. Resident #49's weight on 06/09/22 was 158.6 pounds which was a 26.23% weight loss over a six month period. Review of the dietary progress notes for Resident #49 from December 2021 through the present revealed on 12/10/21 and 12/30/21 former Dietary Technician #930 revealed the resident's weight had been stable and no new dietary recommendations were made. Dietary Technician #930 again noted the resident's weight was stable although there had been no weights obtained since 12/01/21. The dietary progress note dated 03/10/22 by former RD #931 revealed a weight had been obtained on Resident #49 and it was 176.5 pounds. RD #931 added Ensure Plus one time a day and requested a reweight be obtained. RD #909's annual nutrition assessment dated [DATE] revealed Resident #49's current body weight was 197 pounds and he had had a significant weight loss over the past six months. The note indicated the resident had been refusing meals. Resident #49 had been drinking 0-100% of his Ensure Plus, with his intake mostly being around 50% per the medical record. On 04/06/22 Resident #49 had multiple dental extractions on the left side of his mouth. RD #909 interviewed the resident who told her he cannot eat because he has no teeth and it hurts to chew. Resident #49 refused to consider changing his diet to a mechanically altered/chopped diet. RD #909 added nutritional juice with each meal, a nutritional treat at lunch, and chocolate milk with meals. RD #909 next assessed Resident #49 on 06/13/22 and noted his current body weight was 158.6 pounds and identified a significant and severe weight loss of 38.4 pounds over two months and a 56.4 pound weight loss over six months. Resident #49 continued to refuse meals but told RD #909 the food was getting better. RD #909 noted the resident was mostly refusing the interventions implemented in April. The dietician's nutritional interventions put in place on 06/13/22 were to stop the Ensure Plus, the fortified juice, and the magic cup. Enlive eight ounces three times a day was added. Interview with RD #909 on 06/15/22 at 3:09 P.M. revealed she was aware there were no recent weights for Resident #49. She thinks she asked for them a couple of times but is not positive. The dietician said he will refuse weights as well. When asked why a reweight was not requested in April when his weight had been 197 pounds and in March it had been 176.5 pounds, RD #909 said she did not know why she had not requested a reweight. RD #909 said she did not know what percentage of supplements the resident consumed as the facility does not track the intake percentage. She discontinued the fortified juice, Magic Cup, and Ensure Plus because he did not appear to consume it. RD #909 did not know if Resident #49 had started receiving the Enlive she had implemented on 06/13/22. When asked if she had requested an appetite stimulant be ordered for Resident #49, RD #909 said she had not thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 7 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some about that for him, but it was a very good idea. RD #909 said she had not notified the physician regarding Resident #49's weight loss as that was not her job. 5. Resident #53 was admitted to the facility on [DATE] with diagnoses including heart disease, dementia without behavioral disturbance, aphasia after having a stroke, hemiplegia and hemiparesis affecting the right dominant side after a stroke, and Covid-19 on 03/23/21. Review of the physician's orders for Resident #53 revealed on 03/31/21 a Magic Cup was ordered to be provided at lunch and for an evening snack. On 09/28/21 the resident's diet was ordered for a regular diet, pureed texture, with honey like consistency. He may have think liquids if given in a Provale Cup (a limited flow cup for the delivery of thin liquids only which when the cup is tipped only five cubic centimeters (cc) of fluid will be delivered at one time). No further dietary interventions to prevent weight loss were ordered until 06/14/22 when weekly weights were ordered and Ensure Plus twice a day was ordered. If the Ensure Plus was not able to be given in a Provale Cup then it was to be thickened to honey like consistency. Review of Resident #53's weights from December 2021 through the present revealed on 12/03/21 the resident's weight was 188.3 pounds. On 01/10/22 his weight was 186.6 pounds. The next weight on 02/08/22 was 168.2 pounds. A reweight was completed on 02/16/22 and the resident's weight was 170.6 pounds. Resident #53's next weight was not obtained until 04/22/22 and remained exactly the same at 170.6 pounds. He was weighed again on 04/23/22 and the weight was 170.2 pounds. No weights were obtained again until 06/10/22 and it was 153.2 pounds with an 18.64% weight loss over six months. Review of the dietary progress notes for Resident #53 revealed on 01/10/22 revealed the resident's weight had been stable for the previous six months. His weight on 01/10/22 was 186.6 pounds. He was able to feed himself and was consuming approximately 0-75% of his meals. He received a Magic Cup at lunch and in the evening and consumed 100% of them. The next assessment on 02/09/22 revealed Resident #53's weight had dropped to 168.2 pounds and indicated a significant weight loss of 5% over a one month period of time. Former RD #934 recommended a reweight. On 02/16/22 RD #934 reassessed Resident #53. A weight was obtained on 2/16/22 and was noted to be 174.0 pounds. RD #934 identified a significant weight loss of 6.8% over one month. His meal intake was between 26-50% for the previous 14 days. As the resident was aphasic (unable to communicate after a stroke) the resident's wife (Resident #61) was interviewed. Resident #61 said her husband had not been eating well due to disliking the food and not knowing what he is eating due to the pureed texture. RD #934 recommended continuing the Magic Cup and added Med Pass eight ounces at night along with weekly weights for the next four weeks. RD #909 next assessed Resident #53 on 04/15/22. No current weight was available for the resident. The last weight obtained was 174 pounds on 02/16/22. Meal intake was listed at 25-75%. Supplement intake for Magic Cup and Med Pass was noted to be greater than 50%. No new nutritional interventions were implemented. Resident #53 was next assessed by RD #904 on 06/13/22. A weight was obtained on 06/10/22 and was 153.2 pounds. RD #909 noted the resident had a nonsignificant weight loss of 17 pounds for an 18.6% loss over six weeks and had a significant/severe loss of 33.4 pounds for a 17.9% weight loss over six months. His meal intake was noted to be 26-50% which was less than his previous assessment. RD #909 discontinued Med Pass and implemented Ensure Plus eight ounces a day. Weekly weights were also ordered. Interview with RD #909 on 06/15/22 at 2:52 P.M. revealed she does monitor weights and she was pretty certain she had recommended getting a weight for Resident #53. After each weekly visit she emails her list of recommendations to the Director of Nursing (DON), but she does not know what the DON does with them. RD #909 confirmed she had been told the food the facility served was horrible and that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 8 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it was better When Dietary Aide #814 was preparing. The facility was switching food providers so hopefully the food quality will improve. When asked how an 18.6% weight loss over a six week period was considered insignificant when weight loss of 5% over one month, 7.5% over 3 months, and 10% over six months was considered significant. RD #909 said she did not consider 18.6% weight loss to be significant as it did not fall on the one month, three month, or six month time line. RD #909 said she did not know why the request for weekly weights was not followed through on. RD #909 said she thinks the physician ordered Remeron as an appetite stimulant but does not know for sure as she did not notify the physician of Resident #53's weight loss as it was not her job. 6. Resident #56 was admitted to the facility on [DATE] with diagnoses including Covid-19 on 05/17/22, heart disease, congestive heart failure, Bipolar Disorder, morbid (severe) obesity, epilepsy, and paranoid schizophrenia. Review of the physician's orders for Resident #56 revealed on 04/27/22 an order was implemented for Glucerna eight ounces to be administered with each meal. Review of Resident #56's weights from December 2021 through the present revealed on 12/01/21 the resident's weight was 200.0 pounds. On 01/10/22 his weight was 195.2 pounds, no reweight was completed. On 02/08/22 the resident's weight was 203.6 pounds, no reweight was obtained. On 03/01/22 his weight was 190.8 pounds and a reweight was obtained on 03/10/22 and was 188.0 pounds. A weight was obtained on 03/22/22 and Resident #56's weight was 180.2 pounds. A weight was obtained on 04/03/22 and was 171.2 pounds, a reweight was not obtained. A weight was not completed in May due to the resident testing positive for Covid-19. The resident's weight was completed on 06/06/22 and was 152.6 pounds and a reweight was obtained on 06/15/22 and Resident #56's weight was 161.8 pounds. Resident #56 had a severe significant weight loss of 23.70% over six months. Review of the dietary progress notes from December 2021 through the present revealed on 12/22/21 Resident #56's weight had been stable for the previous six months. He was eating between 76-100% of his meals. No nutritional interventions were in place at the time of assessment. The next progress note dated 03/30/22 by RD #909 revealed the resident had been readmitted from the hospital on [DATE] where he had been diagnosed with pneumonia. His readmission weight on 03/22/22 was 180.2 pounds indicating he had had a significant, undesirable weight loss of 5.6% over one month. Glucerna eight ounces three times a day was started to prevent further weight loss. RD #909 did not assess Resident #56 again until 04/24/22. His last weight on 04/03/22 was 171.7 pounds and had now had a significant, undesirable weight loss since over the last one month, three months, and six months. Resident #56 state his usual body weight was between 200 and 205 pounds. The nutritional supplement of Glucerna had been discontinued a few days earlier but RD #909 re-ordered it per the resident's request. No further interventions were implemented to prevent further weight loss. RD #909 assessed Resident #56 next on 06/08/22. His last weight was obtained on 06/06/22 at 152.6 pounds. RD #909 felt the resident contracting Covid-19 on 05/19/22 was the reason he was losing weight. Again no additional nutritional interventions were implemented to prevent further weight loss. Interview with RD #909 on 06/15/22 at 3:17 P.M. revealed she thinks she requested weekly weights be obtained on Resident #56 due to weight loss. When asked about why only Glucerna had been implemented as a nutritional intervention when the resident had continued to lose weight since March, and why not implement fortified foods, Magic Cup, RD #909 said she had not thought about that for Resident #56 and thinks that would have been a good idea. She has not implemented anything else as she believes the reason Resident #56 lost weight was due to Covid-19 despite the fact he had consistently lost weight since December 2021. She believes that Glucerna alone will meet his needs. RD #909 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 9 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some she does not know the percentage of supplement intake Resident #56 is taking as the facility does not monitor percentage intake. RD #909 confirmed she did not notify the physician of Resident #56's weight loss as it is not her job. 7. Resident #67 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, a Stage 4 pressure ulcer to the left heel, wounds to the scrotum and testes, moderate protein calorie malnutrition, diabetes, a Stage 3 pressure ulcer to the left buttock, and congestive heart failure. Review of the physician's orders for Resident #67 revealed on 02/09/22 an order was obtained for weekly weights to be completed due to his diagnosis of congestive heart failure. Review of Resident #67's weights revealed the resident's weight on 03/01/22 was 194.8 pounds. The next weight was obtained on 03/16/22 and was 197.4 pounds. Weekly weights were obtained from 03/16/22 through 05/03/22. No weights were obtained after 05/03/22. Interview with Registered Dietician (RD) #909 on 06/15/22 at 4:00 P.M. revealed she was aware the weekly weights she had ordered were not being done. The physician was not notified as it was not her job. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 10 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an Advanced Beneficiary Notice (ABN) was issued as required for Resident #89. This affected one (Resident #89) of three (Resident's #85, #89 and #900) reviewed for beneficiary notices. The facility census was 88. Residents Affected - Few Findings include: Review of Resident #89's Notice of Medicare Non-Coverage (NOMNC) form for skilled services ending 01/06/22 and signed 01/04/22 revealed there was no ABN provided at the time of the NOMNC. Review of the medical record for Resident #89 revealed and admission date of 08/23/21. Medicare Part A services ended on 01/06/22, and Resident #89 continued to live in the facility until discharge on [DATE]. Interview on 06/08/22 at 2:10 P.M. with Social Service Designee (SSD) #904 verified Resident #89 received a NOMNC but was not provided an ABN as required. SSD #904 stated she was untrained in Medicare or skilled care services related to notification of benefits and in her role as a social service designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 11 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and facility policy and procedure review, the facility failed to ensure all employees were checked against the Ohio Nurse Aide Registry (NAR) prior to or on their first day of work/hire to ensure the employee did not have a finding entered into the State Nurse Aide Registry (NAR) concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property as required. This had the potential to affect all 88 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the personnel file for Licensed Practical Nurse (LPN) #873 revealed a hire date of 12/29/20. The printed evidence of LPN #866 being checked against the NAR was not completed until 01/07/21. Review of the personnel file for State Tested Nursing Assistant (STNA) #868 revealed a hire date of 03/30/21. The printed evidence of STNA #868 being checked against the NAR was not completed until the date the personnel file was requested for review during the survey on 06/08/22. Review of the personnel file for LPN #866 revealed a hire date of 04/26/21. The printed evidence of LPN #866 being checked against the NAR was not completed until 04/28/21. Review of the personnel file for Registered Nurse (RN) #902 revealed a hire date of 02/02/22. The printed evidence of RN #902 being checked against the NAR had no date to determine it was completed prior to or on 02/02/22. Review of the personnel file for Certified Nursing Assistant (CNA) #901 revealed a hire date of 02/24/22. The printed evidence of CNA #901 being checked against the NAR had no date to determine it was completed prior to or on 02/24/22. Review of the personnel file for Administrator revealed a hire date of 05/09/22. The printed evidence of Administrator being checked against the NAR had no date to determine it was completed prior to or on 05/09/22. Review of the personnel file for CNA #888 revealed a hire date of 05/16/22. The printed evidence of CNA #888 being checked against the NAR had no date to determine it was completed prior to or on 05/16/22. Interview on 06/09/22 at 7:48 A.M. with Human Resources Director #908 confirmed screening/checking employees through the Ohio NAR for abuse, neglect, exploitation, and misappropriation was not completed for CNA #888 and #901, LPN #866 and #873, RN #902, STNA #868, and Administrator prior to or on the first date of hire to ensure the employee did not have a finding entered into the state NAR concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. Review of the facility policy, Abuse Prevention Program, revised December 2016, revealed as part of the resident abuse prevention, the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individuals who have had a finding entered into the State NAR concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 12 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 their property. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 13 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview, record review, facility policy review, and review of facility Self-Reported Incident (SRI) #222577, the facility failed to timely report to the State Agency an allegation of abuse involving Resident's #3 and #49 as required. This affected two (Resident's #3 and #49) and had the potential to affect all 88 residents residing in the facility. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/12/20 and diagnoses including bipolar disorder, schizophrenia, cerebral infarction, diabetes mellitus, major depressive disorder, hypertension, epilepsy, and personal history of adult physical and sexual abuse. Review of a quarterly Medicare 5-day Minimum Data Set (MDS) 3.0 assessment, dated 05/12/22, revealed Resident #3 had intact cognition. The assessment indicated Resident #3 was independent and required some staff set-up assistance with activities of daily living. Interview on 06/06/22 at 12:02 P.M. with Resident #3 revealed an allegation about Resident #49 who made negative comments to Resident #3 during the previous week at an activity regarding Resident #3's weight while Resident #3 ate ice cream. Resident #49 allegedly made statements including do you need to keep eating ice cream; and you do not look like you need another ice cream. Resident #49 continued to make derogatory comments to Resident #3 in the smoking area stating Resident #3 needed to comb her nappy hair. On 06/06/22 at 4:20 P.M., during an interview with the Administrator, Resident #3's allegations about Resident #49 were reported. Review of the medical record for Resident #49 revealed an admission date of 06/16/21 and diagnoses including chronic obstructive pulmonary disease, hemiplegia, cerebrovascular disease, hypertension, depressive disorder, anxiety, obesity, and osteoarthritis. Review of an annual MDS 3.0 assessment, dated 04/07/22, revealed Resident #49 had intact cognition. The assessment indicated Resident #49 required extensive one staff assistance for bed mobility, dressing, toileting, personal hygiene, limited one staff assistance for transfers, and physical help of one staff assistance for bathing. Interview on 06/09/22 at 8:59 A.M. with Administrator revealed the allegation of verbal abuse against Resident #49 to Resident #3 was passed along to the Social Service Designee (SSD) #904 on 06/06/22. Administrator confirmed the facility's abuse policy was not implemented and a report to the State Agency was not made. Administrator stated SSD #904 spoke to Residents #3 and #49 and stated it was determined not to be abuse. Review of the grievance/concern log, dated 06/07/22, revealed an entry regarding Resident #3 which indicated Resident #49 insulted her asking about her nappy hair. Resident #49 initially denied it on 06/07/22 then admitted it on 06/08/22. Resident #49 apologized to Resident #3 and now both residents were satisfied. Interview on 06/09/22 at 9:35 A.M. with the SSD #904 confirmed the interviews with Resident's #3 and #49 as entered on the grievance/concern log dated 06/07/22, and indicated the interviews were requested by the Administrator. There was no additional documentation related to the allegation of verbal abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 14 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/09/22 at 4:22 P.M. with Administrator verified the facility did not make a timely report to the State Agency within 24 hours of the reported allegations until 06/09/22 after being questioned during the survey process. Interview on 06/09/22 at 4:26 P.M. with Corporate Regional Administrator #910 revealed the facility chooses what gets reported to the State Agency. Review of SRI #222577, dated 06/09/22, revealed the facility reported to the State Agency on 06/09/22 an allegation of emotional/verbal abuse involving Resident's #3 and #49 with a date of discovery of 06/06/22. Review of facility policy, Abuse Prevention Program, revised December 2016, revealed as part of the resident abuse prevention, the administration will identify and assess all possible incidents of abuse; and investigate and report any allegations of abuse within timeframes as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 15 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review the facility failed to ensure the care plans for Resident's #72 and #76 were comprehensive to include respiratory care and management. This affected two (Residents #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received respiratory care. The facility census was 88. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 10/21/20 and diagnoses of sleep apnea, morbid severe obesity due to excess calories, essential primary hypertension, need for assistance with personal care, and anxiety disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #72 had intact cognition. Resident #72 required extensive two staff assistance for bed mobility, dressing and toileting, extensive one staff assistance for personal hygiene, was dependent on two staff assistance for transfers, and required physical assistance of two staff for bathing. The assessment indicated Resident #72 was always incontinent of urine and bowel and required oxygen within 14 days of the assessment while a resident at the facility. Review of Resident #72's physician orders revealed an order dated 07/17/21 for oxygen at two liters per minute via nasal cannula (NC) every day and night shift related to hypoxemia, and an order dated 09/08/21 for CPAP (Continuous Positive Airway Pressure) machine: setting of 5-20 cm H20 (centimeters of water pressure) every night shift for obstructive sleep apnea. Review of Resident #72's care plan initiated 10/21/20 revealed no focus area for respiratory care to include oxygen use and the use of a CPAP machine with goals and interventions related to the assessment, monitoring, and management of the oxygen and CPAP machine use. Interview on 06/09/22 at 12:12 P.M. with MDS Coordinator #898 verified Resident #72's comprehensive care plan did not include a respiratory focus to include oxygen use and the use of a CPAP machine with goals and interventions related to the assessment, monitoring and management of oxygen and CPAP machine use. 2. Review of the medical record for Resident #76 revealed an admission date of 08/09/18 and diagnoses of Alzheimer's disease, morbid severe obesity due to excess calories, essential primary hypertension, and anxiety disorder. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #76 had intact cognition. Resident #76 required extensive one staff assistance for bed mobility, dressing, toileting, and personal hygiene, extensive two staff assistance for transfers, and required physical assistance of two staff for bathing. The assessment indicated Resident #76 was always incontinent of urine and bowel and required oxygen within 14 days of the assessment while a resident at the facility. Review of Resident #76's physician orders revealed an order dated 03/09/21 to change and date oxygen tubing once weekly every Monday night on night shift, and an order dated 06/18/21 for oxygen at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 16 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few three liters via NC for obesity to maintain oxygen blood levels greater than 92 percent every day and night shift related to anxiety disorder and obesity. Review of Resident #76's care plan initiated 05/13/19 revealed a focus area for altered cardiovascular status related to hyperlipidemia, hypertension, edema, and chest pain dated on 06/12/21 through 06/15/21. Interventions included to administer oxygen as ordered by the physician. There were no focus areas in Resident #76's care plan for respiratory care to include oxygen use with goals and interventions related to the assessment, monitoring, and management of oxygen use. Interview on 06/09/22 at 12:12 P.M. with MDS Coordinator #838 verified Resident #76's comprehensive care plan did not include a respiratory focus of oxygen use with goals and interventions related to the assessment, monitoring, and management of oxygen use. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; incorporate risk factors associated with identified problems; and reflect currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 17 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure weekly weights were obtained per physician orders for three residents (Resident's #29, #31, #67) of nine residents reviewed for weekly weights. The facility census was 88. Residents Affected - Few Findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses including COVID-19, bipolar disorder, schizophrenia, neuromuscular disorder of the bladder, mild intellectual disabilities, and hypothyroidism. Review of the physician's orders revealed on 05/20/22 weekly weights were ordered. Review of Resident #29's weights revealed his admission weight was 222.6 pounds and was not obtained until 03/29/22. His next weight was on 04/06/22 and was 217.0 pounds, on 05/04/22 his weight was 209.0 pounds, and then on 06/09/22 his weight was 200.2 pounds. Weights were not obtained per facility policy upon admission and weekly weights were not obtained as ordered on 05/20/22. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, ventilator dependence, neuromuscular dysfunction of the bladder, shaken infant syndrome, quadriplegia, and seizures. Review of the physician's orders revealed an order was written on 10/20/21 for weekly weights to be obtained for Resident #31. Review of the weights for Resident #31 from February through June 2022 revealed on 02/08/22 the resident's weight was 112.5 pounds. The next weight obtained for Resident #31 was on 03/29/22 and his weight was 117.2 pounds. The next weight obtained was on 04/19/22 and his weight was 118.1. The last weight available for Resident #31 was obtained on 05/24/22 and was 117 pounds. 3. Resident #67 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, a Stage 4 pressure ulcer (full-thickness skin and tissue loss) to the left heel, wounds to the scrotum and testes, moderate protein calorie malnutrition, diabetes, a Stage 3 pressure ulcer (full-thickness skin loss) to the left buttock, and congestive heart failure. Review of the physician's orders for Resident #67 revealed on 02/09/22 an order was obtained for weekly weights to be completed due to his diagnosis of congestive heart failure. Review of Resident #67's weights revealed the resident's weight on 03/01/22 was 194.8 pounds. The next weight was obtained on 03/16/22 and was 197.4 pounds. Weekly weights were obtained from 03/16/22 through 05/03/22. No weights were obtained after 05/03/22. Interview with Registered Dietitian (RD) #909 on 06/15/22 at 4:00 P.M. revealed she was aware the weekly weights she had ordered were not being obtained and said she included that information in the dietary recommendations she emailed to the Director of Nursing (DON) every week after her visits. Interview with the DON on 06/16/22 at 9:15 A.M. revealed RD #909 did email her dietary recommendations weekly and then she forwarded the recommendations on to Licensed Practical Nurse (LPN) #898 for follow up. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 18 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Interview with LPN #898 on 06/16/22 at 11:00 A.M. revealed the DON does email her the dietary recommendations made by RD #909 for her to follow up on. She does what is recommended and then jots a note by the recommendation when it was completed. She did not know why the weights were not being completed as ordered. Residents Affected - Few This deficiency substantiates Complaint Number OH00132108. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 19 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure systems were in place for monitoring weights, implementing nutritional interventions to prevent avoidable weight loss, monitoring the percentage of supplements consumed, assessing weight loss, assessing residents for use of adaptive equipment, assisting residents with eating, notifying the physician of severe avoidable weight loss, and providing palatable food for the residents. This resulted in severe avoidable weight loss affecting five residents (Resident's #24, #29, #49, #53, and #56) of eight residents reviewed for nutrition. Two residents (Resident's #24 and #29) experienced severe avoidable weight loss over a three-month period of time and three residents (Resident's #49, #53, and #56) experienced a severe avoidable weight loss over a six-month period of time. The facility census was 88. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, tremors, psychosis, paranoid personality disorder, and hallucinations. Review of the physician's orders revealed on 06/08/22 the dietitian added the nutritional supplement of Ensure Plus to be administered two times a day. On 06/15/22 weekly weights were ordered for Resident #24 Review of the weights for Resident #24 revealed an admission weight obtained on 03/10/22 of 205.8 pounds. His weight on 06/04/22 was 185 pounds indicating a severe weight loss of 10.11% over three months. Weights were obtained on 03/17/22, 04/02/22, 04/03/22, 05/01/22, 05/02/22, 05/05/22, 06/03/22, and 06/04/22. Resident #24 sustained a 10.06% loss over three months. Review of the dietary progress notes for Resident #24 revealed Registered Dietitian (RD) #909 revealed the admission assessment was completed on 03/17/22. Resident #24's admission weight was 205.8 pounds and he informed RD #909 his usual body weight was around 205 pounds. RD #909 noted the resident had tremors and had swallowing problems with food, especially if he was eating bread. He also complained of his medications sometimes getting stuck in his throat. Dietary interventions included monitoring weekly weights and discussing swallowing problems with speech therapy. RD #909's next assessment was dated 06/08/22. The resident's current weight was 185 pounds and RD #909 indicated it was a significant weight loss of 10.1% over a three-month period. The resident's meal intake was between 51-100% and RD #909 noted the resident does lose food while eating related to tremors. The nutritional interventions implemented were to start Ensure Plus (nutritional supplement) twice a day and obtain weekly weights for the next four weeks. Observation and interview with Resident #24 on 06/15/22 at 11:43 A.M. revealed the resident's lunch tray was on his bedside table located next to his bed. There were two hotdogs on it and the resident appeared to have taken one bite. No other food was on the tray. Resident #24 said he does not eat the food because he does not like it. The resident confirmed he has tremors and food does fall off his utensils when he tries to eat. The facility has not provided him with any special adaptive equipment to help him eat. Interview with RD #909 on 06/15/22 at 3:31 P.M. revealed she was aware Resident #24 did not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 20 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Residents Affected - Some weekly weights completed as ordered. RD #909 said she tried to find out why the weights were not obtained but was unable to provide a reason for his weights not being completed. RD #909 said she also looked at the residents to see if they looked like they were losing weight. RD #909 was also unable to explain why she did not reassess Resident #24 after his admission until June. RD #909 confirmed she did not refer Resident #24 to therapy to assess if adaptive equipment might enable the resident to lose less food from his utensils when he ate or for them to address his swallowing issues but that it would have been a good idea to do that. RD #909 also confirmed she had not notified the physician of the resident's weight loss as it was not her job to do that. Interview with Director of Rehabilitation (DoR) #907 on 06/15/22 at 3:55 P.M. revealed RD #909 had not told them of Resident #24's tremors or his swallowing difficulty, but she will have the resident assessed for both. Interview with DoR #907 on 06/16/22 at 3:00 P.M. revealed Resident # 24's diet was downgraded from a regular diet to a pureed diet due to severe pocketing of food. She confirmed RD #909 had not informed them of the resident's difficulty swallowing or the tremors which cause food to fall off his spoon. Resident #24 was picked up by all three disciplines, speech therapy (ST), occupational therapy (OT) and physical therapy (PT), to address his swallowing difficulties, his tremors, and physical strengthening respectively. 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including COVID-19, bipolar disorder, schizophrenia, neuromuscular disorder of the bladder, mild intellectual disabilities, and hypothyroidism. Review of the physician's orders revealed on 05/20/22 weekly weights were ordered. On 05/05/22 a four-ounce fortified shake (a nutritional supplement) was ordered for lunch and dinner. Six ounces of fortified juice was ordered to be served with breakfast. Review of Resident #29's weights revealed his admission weight was 222.6 pounds and was not obtained until 03/29/22. His next weight was on 04/06/22 and was 217.0 pounds, on 05/04/22 his weight was 209.0 pounds, and then on 06/09/22 his weight was 200.2 pounds. Weights were not obtained per facility policy upon admission and weekly weights were not obtained as ordered on 05/20/22. This resulted in a 10.06% loss over three months. Review of the admission dietary progress note dated 03/23/22 for Resident #29 revealed RD #909 obtained his admission weight from the transfer papers from the hospital as the facility did not have a current weight for him. RD #909 did not reassess the resident next until 05/05/22 after he was readmitted to the facility after being hospitalized for a change in mental status. Resident #29's diet order was for mechanical soft texture with food to be served in bowls. The resident was readmitted with a Stage 3 pressure ulcer (full-thickness tissue loss) to the sacrum. RD #909 noted Resident #29 drank fluids better than eating the food he was served and that he was pocketing food in his mouth. RD #909 implemented nutritional juice with breakfast, a fortified shake with lunch and dinner, and he was to be given Med Pass (a nutritional supplement) four ounces three time a day. RD #909's next assessment dated [DATE] revealed Resident #29 had a significant weight loss of 6.1% since admission. His meal texture was downgraded to pureed foods. He continued to have a Stage 3 pressure ulcer and had also tested positive for COVID-19 on 05/13/22. No new interventions were put into place to prevent further weight loss. Weekly weights were to be obtained once Resident #29 was off quarantine. RD #909 next assessed Resident #29 on 06/09/22. A current weight was not available since he had been identified as a significant weight loss. RD #909 noted the resident looked as if he had lost further weight. RD #909 discontinued the Med Pass supplement and added Ensure Plus twice a day. RD #909 also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 21 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Residents Affected - Some requested a weight be obtained. RD #909 followed up with Resident #29 on 06/13/22 and a current weight was obtained of 200.2 pounds resulting in a 10.1% weight loss since admission. RD #909 attributed the weight loss to having contracted COVID-19. No further interventions were implemented. Observation of Resident #29 on 06/13/22 at 8:18 A.M. revealed the resident was sitting in the common area watching television. His breakfast tray was sitting on the table in front of him. No staff members were present. The resident attempted to drink his Ensure Plus but was unable to pick up the bottle. His breakfast consisted of a rounded beige lump with a yellowish gravy over it. He also had a beige gray substance which had spread out over the plate. At 8:28 A.M. a staff member entered the common area and sat down next to the resident and attempted to feed him his breakfast. Resident #29 refused all food. Observation of Resident #29's lunch meal on 06/13/22 at 12:05 P.M. revealed the resident was in bed and his lunch tray was across the room by his television. The resident's meal consisted of a beige rounded lump of what appeared to possibly be mashed potatoes. The round lump looked like what had been on the resident's breakfast tray. Approximately 25% of the round lump appeared to have been eaten. Another beige lump with yellow gravy over it was also on the tray and none of it appeared to have been eaten. A bottle of Ensure Plus was also on the tray. No staff were in the room with Resident #29. At 12:10 P.M. STNA #843 entered the room and said she had gone to get some milk for Resident #29. STNA #843 said he drank all his Ensure Plus, drank a root beer, then wanted some milk. The aide gave the resident some white milk, and Resident #29 said he wanted chocolate milk. STNA #843 said the kitchen did not have any. When asked what the other beige lump was on Resident #29's plate she replied she thought it was chicken pot pie but was not sure. STNA #843 said she does not think Resident #29 likes the food as he frequently refuses it. Interview with RD #909 on 06/15/22 at 4:00 P.M. revealed she believes Resident #29's weight loss was due to being diagnosed with COVID-19 in May but was unable to explain why the resident had consistently lost weight since admission. RD #909 also did not know if Resident #29 was drinking the supplements she had implemented as the facility did not track how much the resident consumed. RD #909 was aware the weekly weights she had ordered were not being obtained and said she included that in the dietary recommendations she emailed to the DON every week after her visits. RD #909 said she believed Resident #29 did not like the texture of his food and did not know why he got round beige lumps with yellow gravy every meal. RD #909 said she did not add any new interventions to prevent further weight loss as she believed his appetite would increase now that he no longer had COVID-19. RD #909 confirmed she did not notify the physician of Resident #29's weight loss as it was not her job. 3. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting the left nondominant side after a stroke, high blood pressure, depression, seizures, and morbid (severe) obesity. Review of the physician's orders for Resident #49 revealed on 06/13/22 Ensure Clear (a nutritional supplement) was ordered to be given three times a day. On 06/14/22 weekly weights were ordered, and blood work was ordered for weight loss. Review of Resident #49's weights revealed his admission weight on 06/16/21 was 230.0 pounds. On 12/01/21 the resident's weight was 215.0 pounds. No weights were obtained in either January 2022 or February 2022. The next weight the facility obtained was on 03/03/22 at 176.5 pounds. No reweight was obtained. The next weight available was 04/05/22 and was 197.0 pounds. No reweight was obtained. No May 2022 weight was obtained. Resident #49's weight on 06/09/22 was 158.6 pounds which was a 26.23% (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 22 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 weight loss over a six-month period. Level of Harm - Minimal harm or potential for actual harm Review of the dietary progress notes for Resident #49 from December 2021 through the present revealed on 12/10/21 and 12/30/21 former Dietary Technician #930 revealed the resident's weight was stable and no new dietary recommendations were made. Dietary Technician #930 again noted the resident's weight was stable although there had been no weights obtained since 12/01/21. The dietary progress note dated 03/10/22 by former RD #931 revealed a weight had been obtained on Resident #49 and it was 176.5 pounds. RD #931 added Ensure Plus one time a day and requested a reweight be obtained. RD #909's annual nutrition assessment dated [DATE] revealed Resident #49's current body weight was 197 pounds and he had had a significant weight loss over the past six months. The note indicated the resident had been refusing meals. Resident #49 had been drinking 0-100% of his Ensure Plus, with his intake mostly being around 50% per the medical record. On 04/06/22 Resident #49 had multiple dental extractions on the left side of his mouth. RD #909 interviewed the resident who told her he could not eat because he had no teeth and it hurt to chew. Resident #49 refused to consider changing his diet to a mechanically altered/chopped diet. RD #909 added nutritional juice with each meal, a nutritional treat at lunch, and chocolate milk with meals. RD #909 next assessed Resident #49 on 06/13/22 and noted his current body weight was 158.6 pounds and identified a significant and severe weight loss of 38.4 pounds over two months and a 56.4-pound weight loss over six months. Resident #49 continued to refuse meals but told RD #909 the food was getting better. RD #909 noted the resident was mostly refusing the interventions implemented in April 2022. The dietitian's nutritional interventions put in place on 06/13/22 were to stop the Ensure Plus, the fortified juice, and the Magic Cup (nutritional supplement). Ensure Enlive (nutritional supplement) eight ounces three times a day was added. Residents Affected - Some Interview with Resident #49 on 06/15/22 at 11:43 A.M. in the common area revealed he hated the food in the facility which was why he was losing weight. He stated he would not feed the food to a dog. The food was better when Dietary Aide #814 was cooking for the facility, it was actually good then, and he was willing to eat it. Once the facility removed her from the position of cook it went downhill. Resident #49 said no one liked the food in the facility. They were always told the facility was going to fix it, but they never did and then the state agency comes in and tells them they will get it fixed but that never happens either. He agreed to eat breakfast this morning as he got a fried egg but refused the lunch offering of chicken pot pie because it was disgusting. He would like to be able to eat more real eggs, not the eggbeaters. The resident said they recently had tacos and all they got was ground beef with chili spice. They were not given any lettuce, cheese, or tomatoes for it. He stated, it was nasty. They cannot get milk or real eggs, so he does not eat. Interview with Resident #45, who was sitting in the common area with Resident #49, on 06/15/22 at 11:43 A.M. revealed he also hated the food the facility served. Resident #45 agreed with Resident #49 that the food was much better when Dietary Aide #814 was cooking. Ever since she stopped cooking, the food had been horrible. The resident said he used to be a cook and realized the food would never be like what he was used to making, but the food he received in prison was better than what the facility served. He added, at least there he got two slices of bread with each meal. The chicken served by the facility was either tough or bloody, neither of which was good. Interview with RD #909 on 06/15/22 at 3:09 P.M. revealed she was aware there were no recent weights for Resident #49. She thought she asked for them a couple of times but was not positive. RD #909 said Resident #49 refused weights as well. When asked why a reweight was not requested in April when his weight was 197 pounds and in March it was 176.5 pounds, RD #909 said she did not know why she had not requested a reweight. RD #909 said she did not know what percentage of supplements the resident consumed as the facility did not track the intake percentage. RD #909 discontinued the fortified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 23 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 juice, Magic Cup, and Ensure Plus because Resident #49 did not appear to consume it. RD #909 did not know if Resident #49 started receiving the Ensure Enlive she implemented on 06/13/22. When asked if she had requested an appetite stimulant be ordered for Resident #49, RD #909 said she had not thought about that for him, but it was a very good idea. RD #909 said she had not notified the physician regarding Resident #49's weight loss as that was not her job. Residents Affected - Some 4. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including heart disease, dementia without behavioral disturbance, aphasia after having a stroke, hemiplegia and hemiparesis affecting the right dominant side after a stroke, and COVID-19 on 03/23/21. Review of the physician's orders for Resident #53 revealed on 03/31/21 a Magic Cup was ordered to be provided at lunch and for an evening snack. On 09/28/21 the resident's diet was ordered for a regular diet, pureed texture, with honey like consistency. Resident #53 may have thin liquids if given in a Provale Cup (a limited flow cup for the delivery of thin liquids only which when the cup is tipped only five cubic centimeters (cc) of fluid will be delivered at one time). No further dietary interventions to prevent weight loss were ordered until 06/14/22 when weekly weights were ordered and Ensure Plus twice a day was ordered. If the Ensure Plus was not able to be given in a Provale Cup, then it was to be thickened to honey like consistency. Review of Resident #53's weights from December 2021 through the present revealed on 12/03/21 the resident's weight was 188.3 pounds. On 01/10/22 his weight was 186.6 pounds. The next weight on 02/08/22 was 168.2 pounds. A reweight was completed on 02/16/22 and the resident's weight was 170.6 pounds. Resident #53's next weight was not obtained until 04/22/22 and remained the same at 170.6 pounds. He was weighed again on 04/23/22 and the weight was 170.2 pounds. No weights were obtained again until 06/10/22 and it was 153.2 pounds with an 18.64% weight loss over six months. Review of the dietary progress notes for Resident #53 revealed on 01/10/22 Resident #53's weight was stable for the previous six months. His weight on 01/10/22 was 186.6 pounds. He was able to feed himself and was consuming approximately 0-75% of his meals. He received a Magic Cup at lunch and in the evening and consumed 100% of them. The next assessment on 02/09/22 revealed Resident #53's weight had dropped to 168.2 pounds and indicated a significant weight loss of 5% over a one-month period of time. Former RD #934 recommended a reweight. On 02/16/22 RD #934 reassessed Resident #53. A weight was obtained on 2/16/22 and was noted to be 174.0 pounds. RD #934 identified a significant weight loss of 6.8% over one month. His meal intake was between 26-50% for the previous 14 days. As the resident was aphasic (unable to communicate after a stroke) the resident's wife (Resident #61) was interviewed. Resident #61 said her husband had not been eating well due to disliking the food and not knowing what he was eating due to the pureed texture. RD #934 recommended continuing the Magic Cup and added Med Pass eight ounces at night along with weekly weights for the next four weeks. RD #909 next assessed Resident #53 on 04/15/22. No current weight was available for the resident. The last weight obtained was 174 pounds on 02/16/22. Meal intake was listed at 25-75%. Supplement intake for Magic Cup and Med Pass was noted to be greater than 50%. No new nutritional interventions were implemented. Resident #53 was next assessed by RD #909 on 06/13/22. A weight was obtained on 06/10/22 and was 153.2 pounds. RD #909 noted the resident had a nonsignificant weight loss of 17 pounds for an 18.6% loss over six weeks and had a significant/severe loss of 33.4 pounds for a 17.9% weight loss over six months. His meal intake was noted to be 26-50% which was less than his previous assessment. RD #909 discontinued Med Pass and implemented Ensure Plus eight ounces a day. Weekly weights were also ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 24 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Residents Affected - Some Interview with Licensed Practical Nurse (LPN) #827 on 06/15/22 at 12:10 P.M. revealed the facility's Hoyer lift scale was not working accurately. She stated she knew it had been off for a while so had Maintenance Director #824 recalibrate it last week, but it still did not take accurate weights. She informed the Administrator of the problem this morning and he told her he would have it looked at. Interview with RD #909 on 06/15/22 at 2:52 P.M. revealed she does monitor weights and she was certain she had recommended getting a weight for Resident #53. After each weekly visit she emailed her list of recommendations to the DON, but she did not know what the DON did with them. RD #909 confirmed she had been told the food the facility served was horrible and that it was better when Dietary Aide #814 was preparing it. She stated the facility was switching food providers so hopefully the food quality will improve. When asked how an 18.6% weight loss over a six-week period was considered insignificant when weight loss of 5% over one month, 7.5% over 3 months, and 10% over six months was considered significant. RD #909 said she did not consider 18.6% weight loss to be significant as it did not fall on the one-month, three-month, or six-month timeline. RD #909 said she did not know why the request for weekly weights was not followed. RD #909 said she thought the physician ordered Remeron as an appetite stimulant but did not know for sure as she did not notify the physician of Resident #53's weight loss as it was not her job. RD #909 did not how much of the supplements Resident # 53 consumed as the facility did not track intake percentage. RD #909 reviewed the physician's orders and confirmed Remeron had not been ordered for Resident #53. Interview with the DON on 06/16/22 at 9:15 A.M. revealed RD #909 did email her dietary recommendations weekly and then she forwarded the recommendations on to LPN #898 for follow up. Interview with LPN #898 on 06/16/22 at 11:00 A.M. revealed the DON does email her the dietary recommendations made by RD #909 for her to follow up on. She does what is recommended and then jots a note by the recommendation when it was completed. Interview with the DON on 06/16/22 at 11:35 A.M. revealed she does not bring dietary recommendations made by RD #909 to morning meeting. As far as she knows LPN #898 was updating the orders with the recommended dietary interventions and ensuring the changes are made. They do discuss nutrition information at the weekly interdisciplinary team meeting. LPN #898 keeps a log of the dietary interventions put in place and brings it for review. Interview with Regional Nurse #933 on 06/16/22 at 11:37 A.M. through 11:45 A.M. revealed the facility's Hoyer lift scales were obsolete per the company. The vendor was bringing rental Hoyer lift scales to the facility sometime in the next four hours. Everyone will then be reweighed. Regional Nurse #933 said she does not believe there are any logs from the interdisciplinary team meeting as the DON would have returned with them already. 5. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including COVID-19 on 05/17/22, heart disease, congestive heart failure, bipolar disorder, morbid (severe) obesity, epilepsy, and paranoid schizophrenia. Review of the physician's orders for Resident #56 revealed on 04/27/22 an order was implemented for Glucerna (nutritional supplement) eight ounces to be administered with each meal. Review of Resident #56's weights from December 2021 through the present revealed on 12/01/21 the resident's weight was 200.0 pounds. On 01/10/22 his weight was 195.2 pounds, no reweight was completed. On 02/08/22 the resident's weight was 203.6 pounds, no reweight was obtained. On 03/01/22 his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 25 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Residents Affected - Some weight was 190.8 pounds and a reweight was obtained on 03/10/22 and was 188.0 pounds. A weight was obtained on 03/22/22 and Resident #56's weight was 180.2 pounds. A weight was obtained on 04/03/22 and was 171.2 pounds, a reweight was not obtained. A weight was not completed in May 2022 due to the resident testing positive for COVID-19. The resident's weight was completed on 06/06/22 and was 152.6 pounds and a reweight was obtained on 06/15/22 and Resident #56's weight was 161.8 pounds. Resident #56 had a severe significant weight loss of 23.70% over six months. Review of the dietary progress notes from December 2021 through the present revealed on 12/22/21 Resident #56's weight was stable for the previous six months. He was eating between 76-100% of his meals. No nutritional interventions were in place at the time of assessment. The next progress note dated 03/30/22 by RD #909 revealed the resident had been readmitted from the hospital on [DATE] where he had been diagnosed with pneumonia. His readmission weight on 03/22/22 was 180.2 pounds indicating he had a significant, undesirable weight loss of 5.6% over one month. Glucerna eight ounces three times a day was started to prevent further weight loss. RD #909 did not assess Resident #56 again until 04/24/22. His last weight on 04/03/22 was 171.7 pounds and he now had a significant, undesirable weight loss since over the last one month, three months, and six months. Resident #56 state his usual body weight was between 200 and 205 pounds. The nutritional supplement of Glucerna was discontinued a few days earlier but RD #909 re-ordered it per the resident's request. No further interventions were implemented to prevent further weight loss. RD #909 assessed Resident #56 next on 06/08/22. His last weight was obtained on 06/06/22 at 152.6 pounds. RD #909 felt the resident contracting COVID-19 on 05/19/22 was the reason he was losing weight. Again, no additional nutritional interventions were implemented to prevent further weight loss. Observation on 06/15/22 at 11:13 A.M. revealed a tall, very thin resident was weighed on the scale located in the conference room. The resident was Resident #56. His weight was 161.8 pounds. Interview with RD #909 on 06/15/22 at 3:17 P.M. revealed she thought she requested weekly weights be obtained on Resident #56 due to weight loss. When asked about why only Glucerna was implemented as a nutritional intervention when the resident had continued to lose weight since March 2022, and why not implement fortified foods, Magic Cup, RD #909 said she had not thought about that for Resident #56 and thought that would have been a good idea. She did not implement anything else as she believed the reason Resident #56 lost weight was due to COVID-19 despite the fact he had consistently lost weight since December 2021. She believed that Glucerna alone would meet his needs. RD #909 confirmed she does not know the percentage of supplement intake Resident #56 was taking as the facility does not monitor percentage intake. RD #909 confirmed she did not notify the physician of Resident #56's weight loss as it was not her job. Review of the facility's Weight Assessment and Intervention policy, last revised September 2008, revealed weights were to be obtained upon admission, the day after admission, and then weekly for two weeks. If there is a weight change of 5% or more since the last weight, then a reweight is to be taken the next day. If the weight is verified the dietitian is to be notified in writing and the dietitian is to follow up within 24 hours of being notified of the weight change. Significant weight loss was defined as a loss of 5% in one month, 7.5% over three months, and 10% over six months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 26 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Based on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and dated per acceptable standards of nursing practice for Resident's #72 and #76. This affected two (Resident's #72 and #76) reviewed for respiratory care. The facility reported 15 (Resident's #3, #10, #28, #31, #35, #56, #58, #59, #62, #63, #70, #72, #75, #76 and #85) who received oxygen therapy. The facility census was 88. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 10/21/20 and diagnoses of sleep apnea, morbid severe obesity due to excess calories, essential primary hypertension, need for assistance with personal care, and anxiety disorder. Review of Resident #72's physician orders revealed an order dated 07/17/21 for oxygen at two liters per minute via nasal cannula (NC) every day and night shift related to hypoxemia. Observation on 06/06/22 at 11:23 A.M. revealed Resident #72's oxygen NC was not dated. Interview with Resident #72 at the time of the observation stated it was a long time ago when the oxygen tubing was changed, more than a week. Observation on 06/06/22 at 3:22 P.M. with the Director of Nursing (DON) revealed Resident #72's oxygen NC was not dated. Interview at the time of the observation with the DON verified there was no date on Resident #72's oxygen NC to determine when it was last changed and confirmed all oxygen tubing was required to be changed and dated weekly. The DON indicated this was supposed to be completed every Monday on night shift. 2. Review of the medical record for Resident #76 revealed an admission date of 08/09/18 and diagnoses of Alzheimer's disease, morbid severe obesity due to excess calories, essential primary hypertension, and anxiety disorder. Review of Resident #76's physician orders revealed an order dated 03/09/21 to change and date oxygen tubing once weekly every Monday night on night shift, and an order dated 06/18/21 for oxygen at three liters via NC for obesity to maintain oxygen blood levels greater than 92 percent every day and night shift related to anxiety disorder and obesity. Observation on 06/06/22 at 12:20 P.M. revealed Resident #76's oxygen NC had a piece of tape on the oxygen tubing which was old and soiled with the date unreadable. Interview with Resident #76 at the time of the observation stated it was unknown and a long time ago when the last time the oxygen tubing was changed. Interview on 06/06/22 at 12:25 P.M. with the DON verified Resident #76's oxygen tubing did not have a legible date because the tape was old and soiled, and it could not be determined when it was last changed. Interview on 06/09/22 at 10:57 A.M. with the DON revealed the facility did not have a policy or procedure for the staff to reference, but verified the staff was aware and it was the facility's practice to change all oxygen tubing weekly every Monday on night shift. The DON further confirmed there were some residents with orders for changing oxygen tubing and some without but indicated the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 27 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 were aware of the need to change the tubing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 28 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 observation, interview and menu spreadsheet review, the facility failed to follow the menu as written. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Findings include: Review of the spreadsheet for Week One Tuesday, corresponding to 06/07/22 revealed portions of the meal were to be served were as follows: baked ham, three ounces; buttered noodles, four ounces; buttered cabbage, four ounces; applesauce, four ounces; bread; one slice. Residents on a mechanical soft diet were to receive a #6-scoop of ground ham. Residents on a pureed diet were to receive a #6-scoop of pureed ham, a #8-scoop of pureed buttered noodles, a #8-scoop of pureed cabbage and a #16-scoop of pureed bread. Observation of lunch tray service on 06/07/22 starting at 11:48 A.M. revealed the temperatures of the foods to be served were taken with the facility's self-calibrating thermometer by [NAME] #814 and portion sizes were established as follows: cabbage, 197 degrees F, four ounces; buttered noodles, 169 degrees F, three ounces; pureed noodles, 146 degrees F, #12-scoop; pureed cabbage, 149 degrees F, #12-scoop; ground ham, 173 degrees F, #10-scoop. The utensils and portion sizes observed were verified by [NAME] #814 during the observation. During an interview on 06/07/22 at 12:38 P.M. Regional Dietary Manager (RDM) #906 was made aware the facility did not follow the spreadsheet and menu as written for the lunch meal as residents receiving a regular diet were under served buttered noodles and were not served bread; residents receiving a mechanical soft diet were under served ground ham, and residents receiving a pureed diet were under served pureed ham, pureed cabbage, and pureed noodles and were not served pureed bread. This deficiency substantiates Complaint Number OH00132009. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 29 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and menu spreadsheet review, the facility failed to serve palatable meals at appetizing temperatures. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Residents Affected - Many Findings include: Review of the spreadsheet for Week One Tuesday, corresponding to 06/07/22 revealed portions of the meal were to be served were as follows: baked ham, three ounces; buttered noodles, four ounces; buttered cabbage, four ounces; applesauce, four ounces; bread; one slice. Observation of lunch tray service on 06/07/22 starting at 11:48 A.M. revealed the temperatures of the foods to be served were taken with the facility's self-calibrating digital thermometer by [NAME] #814 and were as follows: ham, 197 degrees Fahrenheit (F), 1 slice; cabbage, 197 degrees F, four ounces; buttered noodles, 169 degrees F, three ounces; pureed noodles, 146 degrees F, #12-scoop; pureed cabbage, 149 degrees F, #12-scoop; ground ham, 173 degrees F, #10-scoop. The portion sizes observed were verified by [NAME] #814. Tray service began at 11:56 A.M. During the observation it was noted the pureed ham was runny on the plate and did not keep its shape. A test tray was requested for the last cart which began at 12:29 P.M. The test tray was made at 12:30 P.M. and the cart left the kitchen at 12:32 P.M. The cart arrived on the unit at 12:33 P.M. and tray pass began at 12:34 P.M. The test tray was sampled with Regional Dietary Manager (RDM) #906 at 12:51 P.M. and the foods were sampled with the facility's self-calibrating digital thermometer and were as follows: juice, 44 degrees F; ham, 118 degrees F (top slice) and 125 degrees F (bottom slice); noodles, 116 degrees F; cabbage, 131 degrees F and applesauce 56 degrees F. The food was lukewarm and lacked flavor; the plate did not taste palatable at these temperatures. Interview with RDM #906 during the observation revealed he looked for hot foods to be at least 120-125 degrees F at point of service and verified the test tray was not palatable nor met these temperatures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 30 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation and interview, the facility failed to ensure pureed foods were prepared to the appropriate consistency. This affected eight residents (Resident's #6, #8, #12, #18, #29, #53, #60, #68 and #73) receiving a pureed diet. The facility census was 88 residents. Findings include: Observation on 06/07/22 starting at 11:12 A.M. of purees with Regional Dietary Manager (RDM) #906 and [NAME] #814 revealed no recipe was available during the observation. [NAME] #814 stated the recipe book was in there, referring to the kitchen office. At 11:35 A.M. [NAME] #814 placed a sixth pan full of ham slices into the food processor with an unmeasured amount of pork gravy. The ham slices were noted to still have the skin on them. After blending [NAME] #814 placed the mixture into the sixth pan indicating the puree was completed and ready for service. Upon taste of the mixture there were bits of the ham skin palpable on the tongue and bits of ham skin were also observed in the mixture sampled. RDM #906 then directed [NAME] #814 to re-blend the mixture. During the observed conversation with RDM #906 and [NAME] #814 it was discovered the knife sharpening service was not sharpening the blade to the food processor and this needed to be done going forward. After re-blending, the mixture still contained bits of ham skin. RDM #906 used a strainer and then a colander to remove the ham skin from the mixture and then this smooth mixture was placed on the steamtable for service. Observation of lunch tray service on 06/07/22 starting at 11:56 A.M. revealed during plating, the pureed ham was runny on the plate and did not keep its shape. Interview on 06/07/22 starting at 12:34 P.M. with RDM #906 verified [NAME] #814 should have followed recipes for the purees and the skin should have been taken off of the ham slices prior to pureeing it. RDM #906 also verified finished purees should not run across the plate. The facility's diet list dated 06/06/22 indicated eight residents received a pureed diet (Resident's #6, #8, #12, #29, #53, #60, #68, #73). This deficiency substantiates Complaint Number OH00132041. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 31 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 observation, interview, record review, and facility policy review, the facility failed to ensure a clean and sanitary kitchen. This affected 86 residents receiving meals from the kitchen as two residents (Resident's #31 and #70) were ordered nothing-by-mouth. The facility census was 88. Findings include: Observation of the kitchen on 06/06/22 from 8:59 A.M. to 9:21 A.M. with Regional Dietary Manager (RDM) #906 revealed the following concerns: • There was black material on the inner lip of the ice machine. • Floors were dirty and greasy throughout the kitchen with a higher build-up of grime by the oven and food preparation area. • The hoods had a greasy build-up. • The slicer was under a plastic bag. When the bag was lifted, the slicer was noted to be dirty with meat pieces still on it. • In the cooler, a rack with trays of fruit bowls was present. The plastic lids on the bowls were too small so they sat directly inside the bowls on top of the food that was ready to eat. Interview with RDM #906 verified the above areas of concern at the time of observation. RDM #906 identified the black material on the interior of the ice machine as dirt and indicated the machine needed to be cleaned and was to be cleaned at least once a month. RDM #906 indicated the floors were to be cleaned three times a day and verified the floors needed to be cleaned. RDM #906 stated hoods were to be cleaned every few months and confirmed they needed to be cleaned again. RDM #906 verified the slicer was not clean and should have been cleaned after use and before being re-bagged. RDM #906 stated the lids of the fruit bowls did not appropriately cover the fruit to be served or prevent it from contamination and were too small for the bowls used. Review of the facility's weekly cleaning schedule for 06/05/22 (closing) revealed on Sunday [06/05/22] cleaning items were blank on the second page including the meat slicer being cleaned and sanitized and floors being cleaned and sanitized properly. Review of the undated policy, Production, Storage and Dispensing of Ice, revealed the dispenser (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 32 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 will be cleaned and sanitized at least monthly and or as needed. Inside and outside of machine and the area around the machine will be cleaned. Review of the undated policy, Cleaning Instructions: Hoods and Filters, revealed stove hoods and filters will be cleaned according to a cleaning schedule or at least monthly. Hoods and filters should be cleaned professionally at least yearly. Review of the undated policy, Cleaning instructions: Slicers, revealed the slicer will be cleaned and sanitized after each use. Review of the food storage policy, no date, revealed leftover food will be stored in covered containers of wrapped carefully and securely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 33 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm 6. After review of the medical records for Resident's #24, #29, #49, #53, and #56, the facility failed to ensure systems were in place for monitoring weights, implementing nutritional interventions to prevent additional weight loss, monitoring the percentage of supplements consumed, assessing weight loss, assessing residents for use of adaptive equipment, assisting residents with eating, notifying the physician of severe avoidable weight loss, and providing palatable food for the residents. Residents Affected - Many Interview with Registered Dietitian (RD) #909 on 06/15/22 from 2:50 P.M. through 3:50 P.M. regarding Resident's #24, #29, #49, #53, and #56 revealed she was aware weights were not being monitored as ordered, she did not implement interventions to prevent further weight loss, she did not follow up with the residents after weight loss was identified, and she did not notify the physician of severe significant avoidable weight loss as it was not her job to do so. 3. After review of the kitchen on 06/06/22 and 06/07/22, concerns were identified regarding facility staff following the menu to ensure adequate portion sizes, serving foods at appropriate/palatable temperatures, pureeing foods appropriately and ensuring a clean and sanitary kitchen environment. Interview on 06/06/22 at 8:59 A.M. with Regional Dietary Manager (RDM) #906 indicated he was temporarily assisting the facility as the previous dietary manager was terminated two weeks ago. On 06/07/22 at 2:35 P.M. the Administrator was made aware of the widespread kitchen concerns found during the annual survey. The Administrator indicated he was aware of these concerns and that staff were just holding it together in the kitchen. Review of State Agency (SA) survey documentation for the facility indicated repeated citations were issued in the area of food and nutrition services on 06/14/19, 07/08/21, 08/30/21, 09/23/21, 12/13/21 and 02/16/22 since the previous annual survey completed on 05/16/19. Based on observations, interviews, and record reviews, the facility administration failed to ensure its resources were effectively and efficiently managed to attain and maintain the highest practicable physical, mental, and psychosocial well-being of all 88 residents residing in the facility. Findings include: The following concerns were identified throughout the duration of the annual survey: 1. Record review was conducted of employee personnel files which revealed seven employees (Certified Nurse Aides (CNA's) #888 and #901, Licensed Practical Nurses (LPN's) #866 and #873, Registered Nurse (RN) #902, State Tested Nurse Aide (STNA) #868, and the Administrator) of eleven employee files sampled were not screened/checked through the Ohio Nurse Aide Registry (NAR) for abuse, neglect, exploitation, and misappropriation. Interview on 06/09/22 at 7:48 A.M. with Human Resources Director #908 confirmed screening/checking employees through the Ohio Nurse Aide Registry for abuse, neglect, exploitation, and misappropriation was not completed for CNA's #888 and #901, LPN's #866 and #873, RN #902, STNA #868, and the Administrator prior to or on the first date of hire as required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 34 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 06/09/22 at 8:59 A.M. with the Administrator verified being aware it was required for employees to be checked through the Ohio NAR prior to hire and stated not being sure why there was a problem this year when there was not a problem last year. 2. During an interview on 06/06/22 at 4:20 P.M. the Administrator received a report of an emotional/verbal abuse allegation involving Resident's #3 and #49. Interview on 06/09/22 at 8:59 A.M. with the Administrator revealed the allegation of verbal abuse against Resident #49 to Resident #3 was passed along to the Social Service Designee (SSD) #904 on 06/06/22. The Administrator confirmed the facility's abuse policy was not implemented and a report to the State Agency was not made. The Administrator stated SSD #904 spoke to Resident's #3 and #49 and stated it was determined not to be abuse. Interview on 06/09/22 at 4:22 P.M. with the Administrator verified the facility did not make a timely report to the State Agency within 24 hours of the reported allegation until 06/09/22 after being questioned during the survey process. Interview on 06/09/22 at 4:26 P.M. with Corporate Regional Administrator #910 revealed the facility chooses what gets reported to the State Agency. 4. After review of the resident council meeting minutes, resident concerns were not addressed and followed-up on in an appropriate manner and time frame to ensure resolution and no continued issues occurred. After further review of the resident council meeting minutes and personnel files, LPN #873 and STNA #868 confirmed no disciplinary actions on file. Interview on 06/09/22 at 1:10 P.M. with the Director of Nursing (DON) revealed she acknowledged the form and concerns but did not provide any feedback via the form or return it to the activities department and/or the Activities Director (AD) #800. The DON confirmed no documented evidence of follow-up to the resident concerns. The DON revealed she talked to the staff informally but could not provide any formal documentation. Interview on 06/09/22 at 1:15 P.M. with the Administrator revealed once a concern is voiced during a resident council meeting, it was documented on the resident council follow-up form and provided to the identified department head. The Administrator revealed the form was to be completed and follow-up provided. 5. After an environmental tour from 06/06/22 through 06/09/22, numerous concerns were identified and verified related to a clean, functional, and well-maintained environment, by Housekeeping Supervisor (HSKS) #818 and Maintenance Director (MD) #824. Interview on 06/06/22 at 11:15 A.M. with HSKS #818 revealed the facility did not always have two housekeepers working every day and sometimes only one housekeeper each day. HSKS #818 revealed each resident room and common areas did not get cleaned each day due to staffing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 35 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices during a global pandemic. This had the potential to affect all residents residing in the facility. The facility census was 88. Residents Affected - Many Findings Include: 1. Observation on 06/07/22 Certified Nurse Aide (CNA) #830 was observed sitting at the nurses' station with her N95 mask below her mouth. Interview with CNA #830 said she had just lowered her mask so she could breathe. She confirmed she should be wearing her N95 mask at all times while in the patient care areas. 2. Interview with the Administrator on 06/08/22 at 3:15 P.M. revealed Resident #73 had tested positive for COVID-19. The Administrator said she was asymptomatic and does not have a roommate. The facility is putting up a zip barrier in the doorway to her room for quarantine purposes and an isolation supply cart is being placed outside of her room. Her room had a sink and its own bathroom so they would not have to move her. The receptionist was currently sending out the robocalls notifying the family/responsible party of a COVID-19 positive resident in the facility. They began testing all residents as well as staff. Interview with Resident #37 on 06/08/22 at 4:45 P.M. revealed he was unaware of a patient residing on his wing testing positive for COVID-19. During the interview State Tested Nursing Assistant (STNA) #868 entered the room and Resident #37 told her he had not yet been tested for COVID-19. STNA #868 said she would inform the nurse so it would be done. Observation of the main entrance on 06/08/22 at 5:40 P.M. revealed no sign was posted informing visitors and staff there was COVID-19 present in the building. Observation of the main entrance on 06/09/22 at 8:15 A.M. of the main entrance revealed no sign was posted informing visitors and staff there was COVID-19 present in the building. Interview with the Director of Nursing (DON), who is also the facility's Infection Preventionist, on 06/09/22 at 9:30 A.M. revealed Resident #73 had been tested due to routine testing when they are in outbreak stats. The DON said the facility had been in outbreak status since before the annual survey started. When asked why there is no sign informing staff and visitors the facility was in outbreak status upon entrance to the facility, the DON said they do not post signs regarding being in outbreak status. It was the receptionist's responsibility to inform visitors. The DON had no answer as to who informs staff and visitors entering the facility when the receptionist is not there. 3. Observation on 06/15/22 at 1:35 P.M. revealed STNA #843 was in the room of Resident #139 who was in quarantine due to being a new admit who was not vaccinated against COVID-19. The zip barrier sealing off the resident's room from the hallway was unzipped. STNA #843 was observed wearing an N95 mask and goggles but was not wearing a gown, gloves, or a surgical mask over her N95 mask. The aide was providing care to Resident #139. STNA #843 exited the room after spending five minutes with the resident. STNA #843 exited the room at 1:40 P.M. The aide's N95 mask did not fit appropriately. It was loose fitting with visible gaps between her cheek and the mask. The mask was also located at the tip of STNA #843's nose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 36 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Interview with STNA #843 on 06/15/22 at 1:40 P.M. revealed she had removed her personal protective equipment (PPE) but then Resident #843 asked for further help. When questioned why she did not have a surgical mask over her N95 mask as the sign posted outside of the room indicated was to be worn, STNA #843 had no response. Residents Affected - Many This deficiency substantiates Complaint Number OH00132951. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 37 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, record review, and facility policy review the facility failed to ensure antibiotic usage was tracked for effectiveness. This had the potential to affect all residents residing in the facility. The facility census was 88. Residents Affected - Many Findings Include: Review of the facility's antibiotic stewardship logs from April through June 2022 revealed they tracked the onset date of the infection, the type of infection, the antibiotic the resident was placed on, and if they were placed in isolation. No information was recorded regarding the dosage and duration of the antibiotics or if the antibiotic was to be administered orally, topically, or intravenously. No information was documented regarding if any lab work was obtained or what infection assessment tool or management algorithm was being used for tracking. Interview with the Director of Nursing (DON), who was also the facility's Infection Preventionist, on 06/13/22 at 10:15 A.M. revealed she received her Infection Preventionist certificate on 09/12/21. When asked what system the facility was using to track antibiotic usage such as McGeer or Loeb, the DON said she was unaware of any antibiotic tracking system other than what she tracks on her antibiotic stewardship log. The DON confirmed the facility does not track length of antibiotic use, the route the antibiotic is administered, if the infection was facility or community acquired, or if antibiotic was appropriate for the type of infection the resident had. Review of the facility's Antibiotic Stewardship policy, last revised December 2016, revealed if an antibiotic is indicated, the physician will provide complete antibiotic orders including the name of the drug, the dose, frequency of administration, duration of treatment with a start date and a stop date or the number of days the therapy was to be provided, the route the antibiotic is to be administered by, and indications for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 38 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 - Minimal harm or potential for actual 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 observations and staff interview the facility failed to maintain a clean, functional, and well-maintained environment. This affected 22 residents (Resident's #3, #9, #10, #12, #13, #15, #18, #19, #23, #26, #35, #36, #39, #56, #72, #75, #76, #86, #88, #89, #290, and #388) and had the potential to affect all residents residing in the facility. The facility census was 88. Findings include: 1. Observation on 06/06/22 at 11:45 A.M. of Resident #290's bathroom revealed dried feces all over the toilet bowl. Licensed Practical Nurse (LPN) #896 verified the dried fecal matter at the time of discovery. 2. Observation on 06/06/22 at 10:39 A.M. of the carpet located on the Magnolia Unit in the common area, adjacent to the central nursing station, revealed multiple large stains. Housekeeping Supervisor (HSKS) #818 verified the findings at the time of discovery. 3. Observation on 06/06/22 at 11:15 A.M. of Resident #35's room, revealed a large spot of small white granules, identified as thickener, located near the end of her bed. The Director of Nursing (DON) verified the findings at the time of discovery. 4. Observation on 06/06/22 at 11:55 A.M. revealed debris and dried sticky spills located on the floors around the nurse station, DON office, and outside of rooms belonging to Resident's #9, #10, #12, #13, #15, #18, #23, #26, #36, #56, #72, #75, #76, #88, #89, and #388, all located on the Magnolia unit. HSKS #818 verified the findings at the time of discovery. 5. An environmental tour was conducted on 06/09/22 from 9:42 A.M. to 10:05 A.M. with Maintenance Director (MD) #824. The following was observed and verified at the time of discovery: • Resident #86's window screen located on the outside of the window had a hole in the lower right-hand corner that was not repaired. • Resident #39's air conditioner was older, and the air conditioner duct required a vent cover. • Resident #19 did not have individual control of the thermostat and at night, the room was cold. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 39 of 40 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 365658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057 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 Resident #3's wall in the bathroom was in disrepair with two holes and a missing piece of drywall. Level of Harm - Minimal harm or potential for actual harm • Resident #72 had a hole in the drywall located on the outside of the room. Residents Affected - Many Interview on 06/06/22 from 9:30 A.M. to 9:36 A.M. with Housekeepers (HSK's) #819 and #826 confirmed there were only two housekeepers to clean the facility and rooms were not cleaned daily. Interview on 06/06/22 at 11:15 A.M. with HSKS #818 revealed the facility did not always have two housekeepers working every day and sometimes only one housekeeper each day. HSKS #818 revealed each resident room did not always get cleaned each day due to staffing. This deficiency substantiates Complaint Number OH00132951. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365658 If continuation sheet Page 40 of 40