Health inspection·December 14, 2023

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. Based on observation, medical records review, staff interview and review of facility policy, the facility failed to timely notify the physician of a malfunctioning catheter. This affected one (#53) of one residents reviewed for catheter care. The facility census was 81. Findings include: Review of Resident #53's medical record revealed an admission date of 06/15/23. Diagnoses included osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, COPD, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder. Review of the MDS assessment, dated 11/11/23, Resident #53 was cognitively intact. dependent on staff for activities of daily living (ADLs), including bed mobility, had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and one in-house acquired pressure ulcer. Review of the plan of care, revised 07/12/23, revealed Resident #53 had a supra pubic indwelling catheter related to impaired skin integrity, obstruction uropathy, and benign prostatic hypertrophy. Interventions included change catheter per medical provider order, and as needed (PRN), enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, and providing care to urinary catheter, observe /record/report to physician (MD) signs or symptoms (s/sx) of urinary tract infection (UTI), observe for s/sx of discomfort on urination and frequency, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, provide catheter care every shift and PRN, and notify medical provider if urine is of abnormal color, consistency, or odor. Observation on 12/13/23 at 6:10 A.M., with Licensed Practical Nurse (LPN) #124, revealed Resident #53 in bed. Entry to the room revealed a pervasive odor. Further observation revealed Resident #53 was heavily soiled with liquid stool and urine and the resident's gown was soiled to middle chest. Continued observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtain supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Throughout the observation, Resident #53's urinary indwelling supra-pubic catheter was noted to be leaking from the stoma, with a soiled dressing removed by LPN #101. Additionally, LPN #101 removed a heavily soiled adult incontinence brief and the urinary catheter drainage collection bag was empty. Interview on 12/13/23 at 6:32 A.M. with STNA #112 confirmed she was responsible for Resident #53's care during the night shift, from 10:30 P.M. until 6:30 A.M. STNA #112 stated Resident #53 was last checked at 5:00 A.M. and refused incontinence care or repositioning the entire shift. STNA #112 stated she notified LPN #176 the urinary catheter drainage collection bag was not collecting urine. Interview on 12/13/23 at 6:36 A.M. with LPN #176 revealed she was responsible for Resident #53's care from 6:30 P.M. until 7:00 A.M. LPN #176 verified she was aware Resident #53's urinary catheter drainage collection bag was not collecting urine at the beginning of the shift and she was going to notify the on-coming day shift nurse for further intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 2 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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 Review of facility policy titled Notification of Change in Condition, undated, revealed the facility must consult with the resident's physician when there is a change requiring such notification, including circumstances requiring the need to alter treatment, or implement new treatment. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 3 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, review of the air mattress user manual, and review of facility policy, the facility failed to ensure interventions were consistently implemented to promote skin integrity. This affected one (#53) of three residents reviewed for pressure ulcers. The facility census 81. Residents Affected - Few Findings include: Resident #53 admitted to the facility on [DATE] with the diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, and sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, and left knee, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), had an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one in-house acquired pressure ulcer. Review of the plan of care, revised 11/09/23, revealed Resident #53 had impaired skin integrity and was at risk for altered skin integrity due to immobility, poor nutrition, poor vascularity, and pressure ulcers. Interventions included administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, ankle lift pillows as tolerated, apply appropriate pressure reducing appliances, apply barrier creams post incontinent episodes, complete skin at risk assessment upon admission/readmission, quarterly, and as needed, complete weekly skin checks, educate resident/resident representative on need for turning and repositioning, enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to wound care for skin openings that require a dressing, ensure residents are turned and repositioned, evaluate existing wound daily for changes (redness, edema, drainage, pain, foul odor), keep gerichair close to resident room and encourage use up to daily as tolerated, monitor meal intake, monitor vital signs, notify resident/resident representative, medical provider of any decline in wound healing, nutritional consult on admission, quarterly, and as needed (PRN), offer dietary supplements per medical provider's orders, provide diet as ordered, and provide peri-care as needed to avoid skin breakdown due to incontinence. Review of a physician order dated 11/10/23 revealed Resident #53 was ordered an Alternating Pressure Mattress (APM) to the bed and to check placement, function, and settings according to manufacturer instructions. Additional review of the plan of care, revised 11/13/23, revealed Resident #53 had a behavior problem related to diagnoses of schizophrenia, anxiety, depression, panic disorder, loss of independence, nursing home admission, pain, and psychosocial issues. Resident #53 smoked in his room, refused to have sheets changed, refused to have wound dressing changed, refused to have nails trimmed, scratched self, digs at back side with his nails, throws food trays on the floor and/or at staff, scratched staff when providing care, combative with cares that are being given, refused to turn and reposition, put hands in stool, preferred to wear gowns, refused respiratory medications, refused to get up out of bed, and refused to off load heels. Interventions included administer medications as ordered, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 4 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few educate resident and resident representative to medication effectiveness and side effects, approach, speak in calm manor, encourage active support by family/resident representatives, encourage resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs, and praise any indication of progress in behaviors. Review of a weight, dated 12/06/23 and located in the electronic medical record, revealed Resident #53 weighed 127.2 pounds (lbs). Observation on 12/13/23 at 6:10 A.M. with Licensed Practical Nurse (LPN) #124 revealed Resident #53 in bed. Upon entrance to the room, a pervasive odor was noted. Resident #53 was heavily soiled with liquid stool and urine. Continued observation revealed Resident #53's hospital gown was soiled to middle chest. An air mattress was in use to the bed, with the low pressure indicator light flashing. The air mattress weight was set at 260 pounds. Observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtained supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Resident #53 was noted to have food debris under him, a heavily soiled adult incontinence brief, and a stage IV pressure ulcer dressing heavily soiled and dislodged, with wound packing dangling from the wound. Interview on 12/13/23 at 6:32 A.M. with STNA #112 revealed she was responsible for providing care to Resident #53 during the night shift, from 10:30 P.M. to 6:30 A.M. STNA #53 revealed the resident was last checked at 5:00 A.M. and refused incontinence care and repositioning during the entire shift. STNA #112 stated she notified LPN #176 and no additional interventions or strategies had been attempted to address the resident's incontinence or repositioning needs. Interview on 12/13/23 at 6:36 A.M. with LPN #176 confirmed she had been assigned to Resident #53's care during the night shift, between 6:30 P.M. and 7:00 A.M. LPN #176 stated she was unaware Resident #53 would not allow incontinence care or repositioning throughout the shift. LPN #176 indicated Resident #53 would respond to her regarding turning, repositioning and incontinence care; however, LPN #176 denied being informed of the refusals or the need for intervention. Interview on 12/13/23 at 7:35 A.M. with wound specialist, Certified Nurse Practitioner (CNP) #1, during treatment observation, revealed Resident #53 had multiple pressure ulcers. CNP #1 stated Resident #53 frequently refused treatments and repositioning. The resident had been given education and encouragement to comply with wound treatment. CNP #1 stated Resident #53 agreed to having wounds treated once daily instead of twice daily. Further observation with CNP #1 and LPNs #101, and #124, during pressure ulcer wound evaluation, noted the following wounds: right hip pressure Stage IV measuring 6.8 centimeters (cm) long x 5 cm wide x 0.4 cm deep; right heel pressure Stage IV measuring 6.9 cm x 7 cm x 0.2 cm; sacrum pressure Stage IV measuring 4.5 cm x 4.9 cm x 1.9 cm; left hip pressure Stage IV measuring 0.4 cm x 0.8 cm x 0.1 cm; right medial lower leg pressure Stage IV measuring 13 cm x 6.7 cm x 0.4 cm; left hip distal pressure Stage IV measuring 8 cm x 5.9 cm x 1.2 cm; and left lateral foot pressure Stage IV measuring 1.5 cm x 1.4 cm x 0.2 cm. The bed air mattress was observed to be flashing low pressure and the weight setting was at 260 lbs. Additional observations on 12/13/23 at 11:39 A.M. and 3:20 P.M. revealed Resident #53 in bed with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 5 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the air mattress control indicator light flashing low pressure and the weight setting at 260 pounds. Resident #53 was positioned on his back and lying in hole in the mattress, with limited support. Concurrent interview with Resident #53 confirmed he felt like he was sinking into the mattress and this was not comfortable. Interview on 12/13/23 at 3:27 P.M. with LPN #101, unit manager, revealed the facility did not have access to the air mattress instructions for use due to being supplied by the hospice agency. The facility was contacting the hospice agency for access to the instruction manual. Review of alternating air mattress user manual noted the manual should be used for initial set up of the system and for reference purposes. Further review revealed to turn the pressure adjust knob to set a comfortable level by using the weight scale as a guide. The low pressure indicator notes a visible indicator (yellow or red) and warns the pressure is below a preset or user-defined level. The visible alarm indicator will continue to flash until the air pressure issue was corrected. Once corrected, the alarm function will automatically reset. Interview on 12/13/23 at 3:24 P.M. with LPN #153 revealed she was unaware Resident #53 air mattress was not set at the proper weight setting and unaware the air mattress was flashing low pressure since assuming the shift. Review of facility policy titled Skin Care and Wound Management Overview, undated, revealed the policy was to prevent skin impairment and promote healing of existing wounds. Additionally, a plan of care would be developed with individualized interventions to address risk factors, risk factors and interventions would be communicated to the care giving team, and evaluate for consistent implementation of interventions and effectiveness at clinical meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 6 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure interventions were implemented to timely address bowel incontinence and related indwelling urinary catheter malfunction. This affected one (#53) of two residents reviewed for incontinence and catheter care. The facility census was 81. Findings include: Resident #53 admitted to the facility on [DATE] with diagnoses including osteomyelitis, stage IV pressure ulcer to left buttock, left hip, right hip, right heel, sacral region, venous insufficiency, type II diabetes mellitus, chronic obstructive pulmonary disease, schizoaffective disorder, chronic pain, contracture left hip, right hip, left knee, major depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/11/23, revealed Resident #53 was cognitively intact, dependent on staff for activities of daily living (ADLs), utilized an indwelling catheter, was incontinent of bowel, and admitted with four stage IV pressure ulcers and had one in-house acquired pressure ulcer. Review of the plan of care, dated 07/12/23, revealed Resident #53 had bowel incontinence due to immobility and paraplegia. Interventions included provide assistance with toileting as needed, provide peri-care after each incontinence episode, observe for alterations in skin integrity status, and notify medical provider, resident/resident representative of abnormal findings as needed. Further review revealed Resident #53 had a supra pubic indwelling catheter related to impaired skin integrity, obstruction uropathy, and benign prostatic hypertrophy. Interventions included change catheter per medical provider order, and as needed (PRN), enhanced barrier precautions when dressing/bathing/showering/transferring/personal hygiene, changing linens, toileting and peri-care, providing care to urinary catheter, observe /record/report to physician (MD) for signs or symptoms (s/sx) of urinary tract infection (UTI), observe for s/sx of discomfort on urination and frequency, position catheter bag and tubing below the level of the bladder and provide privacy bag, secure catheter to the leg with security device, provide catheter care every shift and PRN, and notify medical provider if urine is of abnormal color, consistency, or odor. Additionally, the plan of care was revised on 11/13/23 to include Resident #53 had a behavior problem related to diagnoses of schizophrenia, anxiety, depression, panic disorder, loss of independence, nursing home admission, pain, and psychosocial issues. Resident #53 refused to have sheets changed, refused to have wound dressing changed, refused to have nails trimmed, scratched self, digs at back side with his nails, throws food trays on the floor and/or at staff, scratched staff when providing care, combative with cares that are being given, refused to turn and repositioned, put hands in stool, preferred to wear gown, refused respiratory medications, refused to get up out of bed, refused to off load heels, refused care and dressing changes. Interventions included administer medications as ordered, approach, speak in calm manor, encourage active support by family/resident representatives, encourage resident to express feelings, encourage to maintain as much independence and control/decision making as possible, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks that divert attention, monitor behavioral episodes, and attempt to determine underlying causes, observe and anticipate resident's needs: thirst, food, body positioning, pain, toileting needs and praise any indication of progress in behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 7 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 12/13/23 at 6:10 A.M. with Licensed Practical Nurse (LPN) #124 revealed Resident #53 in bed. Upon entrance to the room, a pervasive odor was noted. Resident #53 was heavily soiled with liquid stool and urine. Additional observation noted Resident #53's hospital gown soiled to middle chest. Observation on 12/13/23 at 6:12 A.M. revealed LPN #101 and State Tested Nurse Aide (STNA) #112 obtained supplies and proceeded to provide incontinence care to Resident #53, including a bed bath, clothing change and bed linen change. Throughout the observation, Resident #53's urinary indwelling supra-pubic catheter was noted to be leaking from the stoma. A heavily soiled stoma dressing was removed and the urinary catheter drainage collection bag was empty. Interview on 12/13/23 at 6:32 A.M. with STNA #112 confirmed she provided care to Resident #53 on the night shift, from 10:30 P.M. until 6:30 A.M. STNA #53 stated the resident was last checked at 5:00 A.M. and refused incontinence care or repositioning during the entire shift. STNA #112 stated she notified LPN #176 and no additional interventions or strategies had been attempted to address the residents incontinence or repositioning needs. Furthermore, STNA #112 verified the urinary catheter collection bag did not collect urine during the shift and remained empty. Interview on 12/13/23 at 6:36 A.M. with LPN #176 confirmed she was assigned to provide care to Resident #53 during the night shift, between 6:30 P.M. and 7:00 A.M. LPN #176 revealed she was unaware Resident #53 would not allow incontinence care or repositioning throughout the shift. LPN #176 indicated Resident #53 would respond to her regarding turning, repositioning and incontinence care; however, LPN #176 was not informed of the refusals or the need for intervention. LPN #176 verified she was aware Resident #53's urinary catheter drainage collection bag was not collecting urine at the beginning of her shift and she was going to notify the on-coming day shift nurse for further intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 8 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, family interview, staff interview, review of the facility contingency box medication list, and review of facility policy, the facility failed to ensure medications were available from the pharmacy for timely administration. In addition, the facility failed to secure available medications from the contingency box for administration when resident's medications were unavailable from the pharmacy. This affected five (#2, #68, #284, #285, #287) of nine residents reviewed for medication administration. The facility census was 81. Findings included: 1. Review of Resident #2's medical record revealed an admission date of 11/17/23. Diagnoses included pancreatic cancer, antiphospholipid syndrome, fibromyalgia, breast cancer, thrombocytopenia, and hemiplegia/hemiparesis following a cerebral vascular accident. Review the admission Minimum Data Set (MDS) assessment, dated 11/24/23, revealed Resident #2 had intact cognition. The resident was independent for activities of daily living (ADLs), but required setup or clean-up assistance with eating. Review of Resident #2's most recent care plan revealed she was at risk for abnormal bleeding or hemorrhage due to anticoagulant/antiplatelet use. Interventions included to provide anticoagulant/antiplatelet medication per medical providers order. Review of Resident #2's physician order dated 11/17/23 revealed abatacept subcutaneous solution (anti-inflammatory) auto-injector 125 MG/ML (Abatacept) was to be subcutaneously injected in the morning every seven days for inflammation. Review of Resident #2's Medication Administration Record (MAR) for November 2023 revealed on 11/18/23 and 11/25/23, abatacept subcutaneous solution administration was documented as 9, indicating to see nurses notes. Review of Resident #2's physician order dated 11/17/23 revealed linaclotide (treatment of irritable bowel) oral capsule 145 micrograms (mcg) was ordered. Directions were to give one capsule by mouth every morning for digestive aide. Review of Resident #2's November 2023 MAR revealed linaclotide was documented 9 on 11/18/23 and 11/19/23, which indicated to see nurses notes. Review of Resident #2's physician order dated 11/17/23 revealed Pregabalin (anticonvulsant) oral capsule 75 mg was to be administered every morning and bedtime for health maintenance. The medication was to begin on 11/18/23. Review of Resident #2's November 2023 MAR revealed it was documented as 9 on 11/18/23 for both doses. Review of the nursing progress notes from 11/17/23 through 11/19/23 revealed no information related to the reason Resident #2's medications were not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 9 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the contingency box (c-box - in house available medication) list revealed Pregabalin was available for nursing staff to pull for administration to Resident #2. There was no evidence Pregabalin was pulled from the c-box for administration. Interview on 12/11/23 at 2:48 P.M. with Resident #2 revealed the resident failed to receive medications for two days after she was admitted . 2. Review of Resident #68's medical record revealed an admission date of 06/13/23. Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, congestive heart failure (CHF), and atrial fibrillation. Review of the quarterly MDS assessment, dated 10/01/23, revealed Resident #68 required maximum assist for all ADLS, except eating, which she was independent. Review of Resident #68's medical record revealed a physician's order dated 06/13/23 for Apixaban (anticoagulant) five mg tablet to be administered every morning and bedtime for atrial fibrillation. Additionally, Resident #68 had an order for Diclofenac sodium gel (nonsteroidal anti-inflammatory) external gel 1% to be applied topically to the bilateral knees three times a day for pain. Review of Resident #68's MAR for December 2023 revealed Apixaban and Diclofenac sodium gel had no documentation for administration on 12/10/23 and 12/11/23, evening doses. Review of Resident #68's progress notes, from 12/10/23 and 12/11/23, revealed the notes were silent for a reason Apixaban and Diclofenac sodium gel were not administered. 3. Review of Resident #284's medical record revealed an admission date of 12/04/23. Diagnoses included lung cancer metastasized to the bone marrow and bones, kyphosis, anemia, chronic obstructive pulmonary disease, diabetes mellitus, acute respiratory failure, and spine fusion. Review of the MDS revealed it was in process. Review of Resident #284's care plan revealed the resident had complaints of acute and chronic pain due to a T-5 fracture, spinal fusion, and lung cancer with metastasized to the bone and bone marrow. Interventions included to provide medication per orders and monitor for side effects and effectiveness of the medication. Review of Resident #284's physician orders, dated 12/04/23, revealed the following orders: Mirtazapine (antidepressant) oral tablet 30 mg to be given by mouth at bedtime for depression, Montelukast sodium (anti-inflammatory) tablet 10 mg to be administered by mouth at bedtime for allergies, Budesonide-Formoterol Furnarate inhalation aerosol (controls asthma and improves lung function) 160-4.5 microgram (mcg) two puffs inhaled orally every morning and bedtime for wheezing, and Lantus (antidiabetic) SoloStar 100 units per milliliter (ml) solution pen-injector, inject 10 units subcutaneously at bedtime for diabetes mellitus. Review of Resident #284's MAR for December 2023 revealed on 12/10/23, there was no documentation of administration of the bedtime doses of Mirtazapine, Montelukast sodium, Budesonide-Formoterol Furnarate, and Lantus. Review of Resident #284's nursing progress notes for 12/10/23 revealed the record was silent as to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 10 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 why the medications were not administered. Level of Harm - Minimal harm or potential for actual harm Review of the c-box medication list revealed Lantus and Mirtazapine were available for nursing staff to pull for administration to Resident #284. Further review revealed no evidence the medication was pulled for Resident #284. Residents Affected - Some 4. Review of Resident #285's medical record revealed an admission date of 12/08/23. Diagnoses included right femur fracture, multiple sclerosis (MS), asthma, coronary artery disease, lymphedema, and peripheral autonomic disease. Review of Resident #285's MDS revealed it was in process. Review of Resident #285's care plan revealed no mention of pain control or medication administration. Review of Resident #285's physician orders, dated 12/08/23, revealed the resident had the following medication orders: atorvastatin calcium (anticonvulsant) oral tablet 40 mg one time daily at bedtime for hyperlipidemia; calcium carb-cholecalciferol (calcium supplement) oral tablet 600-5 mg/mcg every morning for a supplement; lisinopril (antihypertensive) oral tablet 40 mg every morning for hypertension; metoprolol tartrate (antihypertensive) oral tablet 25 mg to be administered every morning for hypertension; omega-3 oral capsule (Omega-3 Fatty Acids) one by mouth every morning for a supplement; polyethylene glycol 3350 powder 17 grams (gm) by mouth in the morning for constipation; aspirin oral tablet chewable 81 mg to be administered every morning for prophylactic; carbarazepine (anticonvulsant) oral tablet 100 mg every morning and bedtime for convulsions; fluticasone-salmeterol (corticosteroid) inhalation aerosol powder breath activated 250-50 mcg per actuation to be inhaled every morning and at bedtime for shortness of breath and wheezing; glycerin-hypromellose-peg (artificial tears) 400 ophthalmic solution 0.2-0.2-1 % one drop in both eyes every morning and bedtime for dry eyes; levetiracetam oral tablet(anticonvulsant) 500 mg every morning and bedtime for convulsions; senna-docusate sodium (stool softner) tablet 8.6-50 mg every morning and bedtime for constipation; gabapentin (anticonvulsant) oral capsule 300 mg three times a day for health maintenance; and hydrcodone-acetaminophen (opioid pain medication) tablet 5-325 mg one tablet every eight hours as needed for pain rated over six out of 10 for 14 days. Review of Resident #285's MAR for December 2023 revealed the following: • On 12/08/23, there was no documentation for atorvastatin administration. • On 12/09/23, calcium carb-cholecalciferol was documented as 9, which indicated to see nurses notes. • On 12/09/23, lisinopril was documented as 9. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 11 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 12/09/23, metoprolol tartrate was documented as 9. Level of Harm - Minimal harm or potential for actual harm • On 12/09/23, omega-3 was documented as 9. Residents Affected - Some • On 12/09/23, polyethylene glycol 3350 powder was documented as 9. • On 12/08/23, there was no documentation for aspirin administration. On 12/09/23, aspirin was documented as 9. • On 12/08/23 and 12/09/23, carbarazepine was documented 9. • On 12/08/23, the evening dose of fluticasone-salmeterol was silent for any administration documentation. The 12/09/23 morning dose was documented as 9. • On 12/08/23 and 12/09/23, glycerin-promellose-peg ophthalmic solution, the MAR was silent for any documentation related to administration. • On 12/08/23, levetiracetam administration was blank for the bedtime dose. On 12/09/23, 9 was documented for the morning dose. • The 12/08/23 bedtime dose and 12/09/23 morning dose were both absent of documentation of senna-docusate sodium administration. • On 12/08/23, gabapentin evening dose was absent for documentation of administration. On 12/09/23, both the morning and afternoon doses were documented as 9. Review of nursing progress notes from 12/08/23 through 12/09/23 revealed no information related to the reason Resident #285 did not receive medications as ordered. Review of the c-box medication list revealed atorvastatin calcium, lisinopril, metoprolol tartrate, gabapentin, senna docusate, and levetiracetam were available for nursing staff to removed from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 12 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some c-box for administration. There was no evidence nursing staff pulled the medications for administration to Resident #285. Interview on 12/11/23 at 10:32 A.M. with Resident #285 and her family revealed the resident failed to receive her medications for several days after admission. The resident stated she brought her medication with her from her previous facility so there should have been no reason they were not administered. Interview on 12/14/23 at 7:00 A.M. with Licensed Practical Nurse (LPN) #180 verified Resident #258 was admitted with their own medications but was unaware of why those were not started on admission. 5. Review of Resident #287's medical record revealed an admission date of 12/08/23. Diagnoses included basal cell carcinoma of the scalp and neck, myasthenia gravis, diabetes mellitus, acute respiratory failure. adult failure to thrive, and osteomyelitis. Review of the MDS assessment revealed it was in process. Review of Resident #287's care plan revealed the resident had complaints of acute/chronic pain. Interventions were to follow physician orders for complaint of pain. Review of current physician orders revealed Resident #287 had the following medication orders: gabapentin 100 mg three times a day for health maintenance/neuropathy; Ketonconazole external cream (antifungal) 2% topically daily for a rash until 12/23/23; Lovenox (enoxaparin - anticoagulant) injection 40 mg/ml every 24 hours for circulation; pyridostigmine bromide (treatment for underactive bladder) tablet 60 mg, one and one half tablets every four hours for health maintenance; morphine sulfate ER (opioid) 15 mg twice daily for pain; and Bactrim DS (antibiotic) 800-160 mg Monday, Wednesday and Friday for prophylaxis. Review of the MAR for December 2023 revealed the following: • The afternoon dose on 12/08/23 and the morning and afternoon doses on 12/09/23 of gabapentin were silent for administration documentation. • On 12/08/23, the MAR reflected no documentation related to the administration of Bactrim. • On 12/08/23, pyridostigmine bromide administration was documented as 9 at 1:00 A.M. and 5:00 A.M. and the 1:00 P.M. and 5:00 P.M. doses had no documentation related to administration. Additionally, the 12/10/23 8:00 P.M. dose and the 12/11/23 12:00 A.M. and 4:00 A.M. doses revealed no documentation of administration. • On 12/09/23, no documentation was present for Ketonconazole administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 13 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 • Level of Harm - Minimal harm or potential for actual harm On 12/10/23, enoxaparin injection was documented as 9. • Residents Affected - Some Morphine Sulfate was documented as 9 for the morning and evening doses on 12/10/23 and the 12/11/23 morning dose. Further review of nursing progress notes from 12/08/23 through 12/11/23 revealed no documentation related to the reason Resident #287 did not receive medications as ordered. Interview on 12/13/23 at 11:30 A.M. with Registered Nurse (RN) #178 revealed it usually took one to two days to receive ordered medications from their pharmacy, which was located out of town. Interview on 12/14/23 at 6:58 A.M. with Licensed Practical Nurse (LPN) #180 revealed it took one to two days to receive medications from the pharmacy when a resident was admitted . She was unaware of why the medications were not pulled from the back-up contingent box when available and needed. Interview on 12/14/23 at 9:00 A.M. with the Director of Nursing (DON) revealed, upon admission on [DATE], Resident #285 had all ordered medications with her. The DON confirmed the MAR indicated Resident #285's medications were not administered as ordered and she was unaware of why the medications were not administered. Additionally, the DON verified Residents #2, #68, #284 and #287 did not receive medications as ordered. The DON stated it generally took one to two days for medications to arrive from the pharmacy once ordered. While some of the missed medications were available in the facility's c-box, the DON confirmed nursing staff did not pull medications, as available, to administer to Residents #2, #68, #284 and #287. Review of the facility policy titled Medication Administration, undated, revealed the facility will proved resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 14 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of 10 medication errors were observed out of 43 opportunities for a medication administration error rate of 23.26%. This affected four (Residents #16, #52, #1, #53) of six residents observed during medication administration. The facility census was 81. Residents Affected - Some Findings include: 1. Review of Resident #16's medical record revealed a physician order dated 11/17/23 for Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg) one tablet four times a day for pain scheduled 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. An order dated 06/22/23 for as needed (PRN) Acetaminophen 325 mg two tablets every six hours for pain. Observation on 12/12/23 at 7:17 A.M. noted Licensed Practical Nurse (LPN) #121 obtained Resident #16's medications from the medication cart and proceeded to administer to the resident. Observation noted Resident #16 to complain of left leg pain with facial grimacing. LPN #121 obtained a pain rating of 8 from the resident. LPN #121 returned to the medication cart and stated Resident #16 had a current physician order for Hydrocodone-Acetaminophen 5-325 milligrams (mg), however the medication was not available since the previous day and LPN #121 was unable to access the facility in-house supply due to lack of knowledge. At 7:28 A.M., LPN #121 obtained PRN Acetaminophen 325 mg two tablets and returned to Resident #16's room and administered the two tablets. 2. Review of Resident #52's medical record noted a physician order dated 11/26/22 for levetiracetam oral solution 100 mg/milliliters (ml) give 7.5 ml two times daily for seizures. Prescribed times at 8:00 A.M. and 6:00 P.M. Observation on 12/12/23 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #191 obtaining Resident #52's medications from the medication cart. Medications included levetiracetam oral solution. LPN #52 poured 7.5 milliliters (ml) of solution into a medication cup and proceeded to Resident #52's room. At 9:28 A.M. LPN #191 provided the medication to Resident #52 (approximately an hour and a half late). 3. Review of Resident #53's medical record noted the following physician orders: 12/10/23 Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg two times daily for pain at 9:00 A.M. and 6:00 P.M. 12/06/23 Baclofen 10 mg four times a day for contracture prescribed times 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. 06/15/23 Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 MCG/ACT one puff inhale four times a day for chronic obstructive pulmonary disease prescribed at 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M., 12/10/23 Ativan 0.5 mg every morning (AM) and bedtime (HS) for anxiety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 15 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 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 0759 06/16/23 Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act one inhale every morning and at bedtime for chronic obstructive pulmonary disease given AM and HS Level of Harm - Minimal harm or potential for actual harm 07/19/23 Lyrica 100 mg three times daily for neuropathy at AM, afternoon, and HS Residents Affected - Some 2/06/23 Baclofen 10 mg four times daily for contractures at 9:00 A.M., 12:00 P.M., 6:00 P.M., 9:00 P.M. Observation on 12/12/23 at 12:10 P.M. noted Resident #53 in bed stating he had not received his morning (AM) medications, including pain medication. Resident #53 did not describe his level of pain at the time. Interview on 12/12/23 at 12:12 P.M. with LPN #191 confirmed Resident #53 had not received morning medications. LPN #191 proceeded to obtain Resident #53's medications from the medication cart. Medications included the following: Oxycontin extended release 12 Hour Abuse-Deterrent 40 mg, Baclofen 10 mg, Ipratropium-Albuterol Inhalation Aerosol Solution 20-100 mcg/act, Ativan 0.5 mg, and Fluticasone-Salmeterol inhalation aerosol powder breath activated 500-50 mcg/act. At 12:22 P.M. LPN #191 proceeded to administer the AM medications to the resident and confirmed the medications were provided outside of prescribed time frames. Review of facility's undated Medication Administration policy noted medications are to be administered as prescribed by the provider. Medications will be administered within the time frame of one hour before and up to one hour after time ordered. Always follow manufacturer guidelines for specific medication use. Inhalers direct rinsing mouth after steroid inhaler. Review of Liberalized Medication Administration undated timeframe's as follows: AM starting at 6:00 A.M. and may extend to 11:00 A.M., Afternoon starting at 12:00 P.M. and may extend to 3:00 P.M., PM starting at 4:00 P.M. and may extend to 7:00 P.M. Any medication ordered by the physician for a specific time will be given at that specific time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 16 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure signage and Personal Protective Equipment (PPE) were posted and available to a COVID-19 positive room. This affected one (Resident #17) of one resident observed for isolation. Additionally, the facility failed to ensure staff took off used PPE and practiced hand hygiene when exiting a COVID-19 positive room. This affected two (Residents #38 and #40) of two residents observed in contact with the staff member. The facility census was 81. Residents Affected - Some Findings include: 1. Review of Resident #17's medical record revealed an admission date of 08/31/23. Diagnoses included peripheral vascular disease, chronic obstructive pulmonary disease, nicotine dependence, and COVID-19. Resident #17's COVID-19 diagnosis was added 12/08/23. Review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #17 was cognitively intact. Resident #17 required set up only for activities of daily living. Resident #17 displayed no behaviors during the review period. Review of Resident #17's care plan revised 12/08/23 revealed the resident was on droplet isolation due to positive COVID-19 test results on 12/08/23. Interventions were to include arranging supplies and equipment in resident's room, implement droplet isolation precautions, and explain purpose or isolation precautions necessary to resident and family. Review of Resident #17's physician orders revealed an order dated 12/08/23 for Contact/Droplet Precautions every shift for COVID-19. Observation on 12/11/23 at 9:34 A.M. of Resident #17's room found red tape along the top and left side of the door. No PPE was available and no signage was posted indicating Resident #17 was on droplet isolation precautions. Interview on 12/11/23 at 9:37 A.M. with Licensed Practical Nurse (LPN) #121 revealed she was not sure if Resident #17 was still considered positive. She verified there was no signage or PPE outside his room. LPN #121 stated the COVID-19 positive residents typically had signs and PPE available. Interview on 12/11/23 at 9:39 A.M. with State Tested Nursing Assistant (STNA) #172 revealed he double checked with the unit manager and verified Resident #17 was still on isolation precautions for COVID-19. Review of the facility policy titled, Criteria for COVID-19 Requirements, revised 05/11/23 revealed appropriate signage was to be placed on or around the resident's room door, full PPE was required when entering the room which was to include N95 mask, eye protection, gown and gloves. Full PPE should be located at or near the entrance of the resident's room. 2. Observation 12/11/23 at 1:33 P.M. revealed the food cart arrived to the 300 hall and staff began passing trays to residents. Business Office Manager (BOM) #183 was observed to put on PPE and entered a COVID positive room with two residents inside (#38 and #40). The STNA passed the trays one at a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 17 of 18 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 365704 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Healthcare Center 955 Garden Lake Pkwy Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time to the BOM while she was wearing the PPE (N-95, gown, gloves, and faceshield) in the room. A resident declined his food and requested a sandwhich from the kitchen so BOM informed the STNA who left to go to the kitchen. While waiting, BOM #193 stood in the doorway conversing with staff who walked by including an additional aide, maintenance staff, and a nurse. After several minutes of standing in the doorway, BOM #193 exited the room and removed the faceshield, gown and gloves while keeping the exposed/soiled N-95 on and also did not preform hand hygiene after exiting the room. BOM walked through the hallway by numerous residents at the nurses station, residents sitting in the hallway and sitting by the front desk/lobby area. BOM #183 then walked back to her office where she interacted with staff. Interview on 12/11/23 at 1:41 P.M. with BOM #183 confirmed she did not properly remove and dispose of a dirty N-95 mask and did not preform hand hygiene. She revealed she was hot and did not even think about it. BOM #183 reported she was supposed to removed the dirty N-95 mask when exiting the room and place a clean mask on while being in the halways and common spaces. Review of the policy titled, Criteria for COVID-19 Requirements, dated 05/11/23 revealed full PPE was required when entering a residents room including N-95 mask, eye protection, gown and gloves. The PPE should be discarded before exiting the residents room. This deficiency represents non-compliance investigated under Complaint Number OH00148942. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365704 If continuation sheet Page 18 of 18