Inspection·September 11, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of the urine culture test results with the specimen collection date 08/11/23, and reported date of 08/14/23 revealed Resident #2 was noted to have the following organisms in her urine, 1) Pseudomonas Aeruginosa with a greater than 100,000 Colony Forming Units (CFU)/milliliter (ml) growth, 2) Klebsiella Pneumoniae with a greater than 100,000 CFU/ml growth and 3) Enterococcus Faecalis with a greater than 100,000 CFU/ml growth. Residents Affected - Few Review of physician note dated 08/14/23 created by MD #600, revealed, Suprapubic pain 08/08/23 change Foley, ordered a urinalysis and culture and sensitivity and labs. 08/14/23 patient complaining of dysuria, urinalysis, culture and sensitivity previously obtained and pending. Appears patient's Foley was not changed, ordered Foley to be changed and repeat testing to be obtained from new Foley. Per chart review, it appears that patient had refused Foley chromophil (on multiple occasions) while at the hospital due to inability to use PureWick. Would recommend readdressing Foley removal and initiation of voiding trial. Patient was complaining of dysuria (painful urination), states that she is itching and burning at the site of her Foley catheter insertion. Review previous notes, it looks like there had been an order to change Foley but this appears not to have been done. Urinalysis obtained from old Foley and is pending at time of assessment. Plan to change Foley today and resend urine tests. Review of progress note dated 08/14/23 at 12:43 P.M. revealed, Urine results received and given to attending Nurse Practitioner (NP) orders to continue with culture and sensitivity. This nurse phones the lab clarifies to culture urine. Family states the resident complains of dysuria, new order in place for Pyridium (a analgesic to relieve symptoms caused by a urinary tract infection). Review of physician note dated 08/15/23 created by [NAME] revealed, 08/15/23-recollect urinalysis and culture/sensitivity due to initial result contaminated, then remove Foley as patient in agreement. Review of progress note dated 08/16/23 at 4:23 P.M. revealed, Urine results received, notified attending NP with new orders for Macrobid (antibiotic) 100 milligrams (mg) for 7 days. Continued review of the urine culture lab test results resulted on 08/14/23 indicated under the antibiotic sensitivity that the prescribed antibiotic Macrobid was sensitive for two of the three organisms, Klebsiella Pneumoniae, and Enterococcus Gaecalis but no sensitivity was indicated at all for the organism Pseudomonas Aeruginosa. Review of Resident #2's plan of care dated 08/22/23 and revised 08/27/23 revealed resident is incontinent of bladder related to diagnosis. Resident #2 was noted to have a order for her Foley catheter to be removed and discontinued on 08/16/23. No evidence of a care plan was noted for Resident #2's Foley catheter before it was discontinued on 08/16/23. Interview on 09/06/23 at 3:30 P.M. with the Administrator confirmed Resident #2's medical record lacked physician orders for Foley catheter care and maintenance and also confirmed Resident #2's Foley catheter was not changed on 08/08/23 prior to a urine sample being collected and sent for testing as per physician order. Interview on 09/06/23 at 3:40 P.M. with Regional Nurse #1 confirmed the antibiotic Macrobid prescribed for Resident #2 was only sensitive to two of the three identified organisms in the residents urine according to the urine culture reported on 08/14/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 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 365717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Convalarium of Dublin 6430 Post Rd Dublin, OH 43016 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 This deficiency represents non-compliance investigated under Master Complaint OH00145635. 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: 365717 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 365717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Convalarium of Dublin 6430 Post Rd Dublin, OH 43016 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 medical record review, staff interview, review of video surveillance, and facility policy review, the facility failed to ensure direct care staff wore the required personal protective equipment while providing incontinent care for a resident in contact isolation. This affected one (Resident #1) of the five residents reviewed for incontinence care. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed and initial admission date of 11/17/22 and a re-entry date of 12/27/22. Diagnosis included chronic respiratory failure with hypercapnia, bipolar disorder, PTSD, adjustment disorder with depressed mood, borderline personality disorder, and chronic pain syndrome. Review of Resident #1's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating resident had an intact cognition for daily decision making abilities. Resident #1 was noted to reject care or evaluation. Resident #1 was noted to receive antibiotic daily. Review of the plan of care date 08/31/23 and revised 09/02/23 revealed Resident #1 was receiving antibiotic therapy for infection related to Pseudomonas in the urine results, intravenous antibiotic via peripherally inserted central catheter (PICC) line and contact isolation. Interventions included administer medication as ordered, assess and document reaction to antibiotic, no blood pressure in the left arm, provide care of PICC line site as ordered, and review lab values as indicated. Review of progress note dated 08/31/23 at 5:43 P.M. created by Licensed Practical Nurse (LPN) #223 revealed Certified Nurse Practitioner (CNP) #575 returned call with new order as follows: Intravenous Cefepime (antibiotic) 1 gram every 12 hours for 7 days. Review of a video surveillance recording located in Resident #1's room dated 09/03/23 revealed a direct care staff member providing incontinence care for Resident #1 with only gloves on. Resident #1 can be heard telling the direct care staff member she needed to wear a isolation gown because she her urine is contagious. The direct care staff continued to provide incontinent care with out the proper personal protection equipment. Resident #1 can then be heard telling the direct care staff member that her top sheet was wet and needed to be changed. The direct care staff member was observed balling up the top sheet and then placing it under her arm next to her body then walking out of the residents room without placing the soiled top sheep in the proper container and without completing hand hygiene and still wearing the same gloves worn to provide incontinence care for Resident #1. Observation on 09/05/23 at 12:20 P.M. revealed a sign posted on the room door for Resident #1 indication resident was in contact isolation. Also noted outside the room door was a plastic container with three draws. Inside the container was isolations gowns, gloves, and disinfectant cleaning wipes. Interview on 09/05/23 at 12:30 P.M. with Registered Nurse (RN) #219 revealed Resident #1 was currently in contact isolation due to having Pseudomonas in the urine. RN #219 claimed the personal protective equipment (PPE) required for a resident in contact isolation include gloves and a isolation gown. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 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 365717 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Convalarium of Dublin 6430 Post Rd Dublin, OH 43016 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 - Few Review of the video surveillance recording located in Resident #1's room dated 09/05/23 revealed a direct care staff member enter Resident #1 room with just gloves on and no isolation gown. Resident #1 can be heard telling the staff member she needed to put a isolation gown on prior to providing incontinence care and the direct care staff member can be heard asking her why, urine will not splash up on her. Interview on 09/06/23 at 2:30 P.M. with the Administrator confirmed the observations of direct care staff providing incontinent care for Resident #1 without wearing the proper PPE for a resident in contact isolation. Review of facility policy titled Standard Precautions revised 08/2022 revealed Contact Precautions, contact precautions are intended to prevent transmission of infections that are spread by direct or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering the room or cubical. Prior to leaving the resident's room or cubicle, the PPE is removed and hand hygiene is preformed. This is an incidental finding identified during the investigation under Master Complaint OH00145635 and Complaint Number OH00145586. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 5 of 5