Health inspection·September 13, 2021

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure residents were free from unnecessary psychotropic drugs when the facility failed to ensure as needed orders for anti-anxiety medications (Lorazepam) was limited to 14 days. This affected three (#21, #5 and #15) out of five residents reviewed for unnecessary medications. Facility census was 23. Findings include: 1. Review of medical record for Resident #21 revealed an admission on [DATE] with cognitive deficits. Diagnoses include congestive heart failure, cardiac arrhythmia, heart failure, type two diabetes mellitus, and hypertension. Review Resident #21's minimum data set (MDS) assessment, dated 08/10/21 revealed resident requires one person assist with activities of daily living. A care plan relative to psychological and medical needs revealed individualized interventions with measurable goals. Review of the Medications Administration Record (MAR) dated 09/01/21 revealed Resident #21 receives Lorazepam tablet 0.5 milligrams (mg) one tablet by mouth every four hours as needed for Anxiety. Review of the Physician summary order report revealed on 08/03/21 Resident #21 was ordered Lorazepam Tablet 0.5 mg one tablet by mouth every four hours as needed for Anxiety. Review of the physician progress notes revealed no documentation to indicate review of the medication or the reason to continue the medication as needed. On 09/08/21, at 11:40 A.M. interview with Registered Nurse (RN) #27 verified the physician had not reviewed or documented on the use of Lorazepam for Resident #21 every 14 days and there was no stop date for the Lorazepam. 2. Resident #5 admitted on [DATE] with diagnoses that included but were not limited to end stage renal disease, hypo-osmolality and hyponatremia, acidosis, sepsis, hypertensive heart failure, and acute pulmonary edema. Review of most recent MDS assessment dated [DATE] revealed Resident #5 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. The resident was a two-person physical assist, and required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene, and total assistance with transfers and locomotion. Review of care plan dated 06/18/2021 revealed Resident #5 admitted to hospice services due to terminal disease presence. She is prescribed Anxiolytic medications to ease breathing and to decrease Anxiety. Interventions included administer anti-anxiety medications as ordered and monitor for side effects/effectiveness, educate resident/family to risks versus benefits, monitor for target behavior symptoms. Further review of care plan revealed the resident was at risk for changes in mood/behaviors related to chronic pain, cognitive communication deficit, and history of cerebrovascular accident. Resident #5 had history of expressing feeling down and having trouble sleeping, history of having low (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365671 If continuation sheet Page 2 of 5 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 365671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Worthington Christian Village 165 Highbluffs Blvd Columbus, OH 43235 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few energy and feeling bad about self, history of telling staff she gets a bed bath then reporting she wasn't bathed, and history of declining medications, insulin, preventative interventions, and false allegations due to forgetfulness. Interventions included arrange for psych consult/follow-up as needed, individualized activities program, encourage the resident to express feelings, offer intervention/distraction as needed for behaviors (TV, religious music, talking), encourage meds and treatments as ordered, report signs and symptoms of depression, and offer adequate rest periods. Review of the medical record revealed Resident #5 had physician orders dated 08/18/21 for Ativan Tablet 0.5 mg tablet by mouth every four hours as needed for anxiety for 90 days. 3. Record review revealed Resident #15 admitted on [DATE] with diagnoses that included but were not limited to chronic diastolic heart failure, unspecified dementia, and hypertension. Review of most recent MDS assessment dated [DATE] revealed the resident had severely impaired cognition, had verbal behaviors, did not wander, and did not reject care. The resident was a two-person physical assist and required extensive assistance with transfers, eating, toileting, and personal hygiene, and total dependence with transfers and locomotion. Review of physician orders revealed Resident #15 had orders on 12/23/20 for Ativan tablet 0.5 mg by mouth as needed for anxiety during the night (last ordered 04/30/21). Interview on 09/09/2021 at 9:03 A.M. Administrator verified Resident #15's as needed Ativan was continued beyond 14 days. Attempt to interview House Physician #9 via telephone on 09/09/2021 at 3:19 P.M. was unsuccessful. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365671 If continuation sheet Page 3 of 5 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 365671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Worthington Christian Village 165 Highbluffs Blvd Columbus, OH 43235 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure a sanitary environment for food preparation. This had the potential to affect all 23 residents residing in the facility. Facility census was 23. Residents Affected - Many Findings include: 1. Observation on 09/07/21 at 9:22 A.M. revealed a fan, approximately 18 inches in diameter, attached to the wall in the dishroom. The fan was observed on and faced toward clean dishes within the dish room and had a black, sticky, and furry substance all over the front and back of the fan. Interview on 09/07/21 at 9:22 A.M., Director of Dining Services (DDS) #72 verified the fan in the dish room had a black, sticky, and furry substance on the front and back surfaces. 2. Observation on 09/08/21 at 10:35 A.M. revealed the DDS #72 in the kitchen wearing a hairnet with her bangs uncovered. DDS #73 prepared pureed deviled eggs, ham salad, and carrots with a blender. Interview on 09/08/21 at 10:50 A.M., DDS #72 verified the hairnet did not fully cover her hair and further stated, it keeps falling off. DDS #72 removed the hairnet and placed it in the trash. Observation on 09/08/21 at 10:52 A.M. revealed DDS #72 remained in the kitchen not wearing a hairnet. DDS #72 was observed checking temperatures of foods on the steam table and entered the the walk-in refrigerator. Interview on 09/08/21 at 10:58 A.M., DDS #72 verified she was not wearing a hairnet and stated she forgot to put on a new hairnet when she removed the previous hairnet. 3. Observation on 09/08/21 at 10:45 A.M. revealed a large trash can uncovered near the food preparation area and a large trash can in the food preparation area, which was partially covered, and a large trash can in the dish room, which was not covered. Interview on 09/08/21 at 10:50 A.M. DDS #72 verified the trash cans in the food preparation area and dish room were not covered. The lid for the trash can in the food preparation area was located behind a storage rack and the lid for the trash can in the dish room was located beside the sink 4. Observation on 09/08/21 at 10:51 A.M. revealed DDS #72 washed and dried her hands with a paper towel, lifted the lid to the trash can with her bare hand, and placed the paper towel in the trash can. Concurrent interview on 09/08/21 at 10:51 A.M., DDS #72 verified she touched a contaminated surface immediately after washing her hands. The facility confirmed all 23 residents receive meals from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365671 If continuation sheet Page 4 of 5 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 365671 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Worthington Christian Village 165 Highbluffs Blvd Columbus, OH 43235 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 observation and staff interview, the facility failed to ensure a safe environment when staff propped open a fire door. This had the potential to affect all 23 residents residing in the facility. Facility census was 23. Findings include: Observation on 09/07/21 at 9:18 A.M. revealed the fire door leading to the kitchen to a hallway propped open with a plastic dish rack. Interview on 09/07/21 at 9:18 A.M., Director of Dining Services (DDS) #72 verified the door was propped with a plastic dish rack. DDS #72 further confirmed the door was a fire door and should not be propped. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365671 If continuation sheet Page 5 of 5