Inspection·February 7, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm was unaware Resident #34 was previously in her room with the call light on for about an hour prior to going to smoke. STNA #208 was unable to provide a response as to why the call light had not been answered. Observation on 02/05/24 at 11:45 A.M. revealed Resident #34 and #35 returned from their isolation smoke break and STNA #208 went to check on Resident #34. Residents Affected - Few Interview on 02/05/24 at 12:45 PM with Corporate Administrator #210 verified the expectation was for call lights to be answered timely. Review of facility policy titled, Call Lights, dated 08/2023, revealed staff should promptly respond to calls for assistance to provide a safe environment and meet care needs. This was an incidental finding over the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 2 of 16 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 02/07/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure an allegation of sexual abuse was reported to the state agency in a timely manner. This affected one (Resident #100) of three reviewed for abuse. The census was 79. Findings included: Closed medical record review for Resident #100 revealed an admission date of 09/13/23. Diagnoses included bilateral trans radial amputation, Cystic Fibrosis, anemia, heart failure, pneumonia, diabetes, anxiety, depression, bilateral trans radial amputation, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact. Her functional status was partial/moderate assistance for eating and toileting and she required supervision for transfers and bed mobility. The resident had impairment to bilateral upper extremities. Review of the investigation dated 01/03/24 revealed Resident #100 reported her cell phone was missing and blamed it on the Maintenance Man (MM) #150 because she was texting with MM prior to a care conference, and he knew she would be gone from the room. She reported she and the MM had been in a sexual relationship since 10/01/23 and they leased an apartment together. Resident #100 stated it was a consensual relationship and she felt safe in the facility. Review of a statement by MM revealed he acknowledged he had been helping Resident #100 in the community to obtain housing and if she didn't get housing, she would lose her kids. He stated he didn't let anyone know about this because Resident #100 told him if he did, she would tell everyone they were having sex. MM #150 admitted he had problems in his marriage. He was educated on professional boundaries with residents. He was informed of the allegation about the phone and was suspended pending further investigation for misappropriation. He adamantly denied he had a sexual relationship with Resident #100. Review of Self-Reported Incidents (SRI) for January 2024 revealed no SRIs related to sexual abuse regarding Resident #100 and MM #150. Interview with State Tested Nursing Aide (STNA) #151 on 02/06/24 at 7:47 A.M. revealed she took care of Resident #100 on multiple occasions and the resident confided in the aide on 01/03/24 she was having a sexual relationship with MM #150 since 10/01/23. The resident said they were having sex in her room at the facility, in her hospital bed during appointments, and when the MM took her out shopping in his truck before coming back to the facility. The STNA felt this was reportable, so she reported it to the Administrative Assistant (AA) #155. Interview with AA #155 on 02/06/24 at 9:55 A.M. revealed STNA #151 came to her and reported Resident #100 and MM #150 were having a sexual relationship. She stated she went immediately into the Administrator's office and reported the allegation. Interview with Administrator #156 on 02/06/24 at 11:05 A.M. via telephone confirmed she didn't file an SRI for the reported sexual relationship between MM #150 and Resident #100 because she didn't feel it was abuse, because he denied the allegation and the resident said it was consensual. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 3 of 16 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 02/07/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, not dated, revealed the facility will submit an online Self-Reported Incident form in accordance with ODH's then-current instructions. This deficiency represents non-compliance investigated under Complaint Numbers OH00149981, OH00150001 and OH00150405. Event ID: Facility ID: 365717 If continuation sheet Page 4 of 16 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 02/07/2024 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 0610 Respond appropriately to all alleged violations. 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, and policy review, the facility failed to complete a thorough investigation related to sexual abuse. This affected one (Resident #100) of three residents reviewed for abuse. This had the potential to affect nine (Residents #35, #52, #80, #6, #7, #51, #2, #63 and #101) Maintenance Man (MM) #150 had contact with. Additionally, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #65) of three residents reviewed for abuse. The facility census was 79. Residents Affected - Some Findings included: 1. Closed medical record review for Resident #100 revealed an admission date of 09/13/23. Diagnoses included bilateral trans radial amputation, Cystic Fibrosis, anemia, heart failure, pneumonia, diabetes, anxiety, depression, bilateral trans radial amputation, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact. Her functional status was partial/moderate assistance for eating and toileting and she required supervision for transfers and bed mobility. The resident had impairment to bilateral upper extremities. Review of the investigation dated 01/03/24 revealed Resident #100 reported her cell phone was missing and blamed it on the Maintenance Man (MM) #150 because she was texting with MM prior to a care conference, and he knew she would be gone from the room. She reported she and the MM had been in a sexual relationship since 10/01/23 and they leased an apartment together. Resident #100 stated it was a consensual relationship and she felt safe in the facility. Review of a statement by MM revealed he acknowledged he had been helping the Resident #100 in the community to obtain housing and if she didn't get housing, she would lose her kids. He stated he didn't let anyone know about this because Resident #100 told him if he did, she would tell everyone they were having sex. He admitted he had problems in his marriage. He was educated on professional boundaries with residents. He was informed of the allegation about the phone and was suspended pending further investigation for misappropriation. He adamantly denied he had a sexual relationship with Resident #100. There were no staff or witness statements included in the investigation and there was no evidence additional residents were interviewed to see if there was potential sexual contact with MM #150. Review of Self-Reported Incidents (SRI) for January 2024 revealed no investigation related to sexual abuse regarding Resident #100 and MM #150. Further review revealed an SRI dated 01/03/24 related to misappropriation regarding Resident #100's missing cellphone, but the SRI did not address sexual abuse allegations. MM #150 was suspended pending an investigation related to misappropriation but was not suspended pending an investigation related to sexual abuse. Review of the work order request forms from 01/03/24 through 02/06/24 revealed Resident's #35, #52, #80, #6, #7, #51, #2, #63 and #101 had completed work orders with the MM #150. Interview with Administrator #156 on 02/06/24 at 11:05 A.M. via telephone confirmed she didn't do a thorough investigation related to the sexual abuse allegation regarding Resident #100 and MM #150. 2. Review of the medical record for Resident #65 revealed an admission date of 03/22/23. Diagnoses included cirrhosis of the liver, muscle weakness, chronic pain and diverticulitis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 5 of 16 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 02/07/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact and required supervision assistance with activities of daily living. Review the progress notes dated 01/01/24 to 02/05/24 revealed no mention of Resident #65's accusation of another resident or visitor taking money from her. Residents Affected - Some Review of the Self-Reported Incident (SRI) revealed the facility submitted a report to the state agency on 01/12/24. The SRI investigation included speaking with the involved victim, Resident #65. No interview statements were included of the Resident Victim (Resident #65), the Resident Perpetrator (Resident #100), any other residents or any staff. The facility did not include any review of the resident's phone to review her online banking statements, any review of banking statement on paper, and no conversations with bank representatives. There was no specific information as to what date this incident occurred and how much money was reported missing. The facility reported they would assist the resident in follow up with the bank in an effort to recover funds and included no evidence of any assistance or follow-up and no report was made to law enforcement. Interview on 02/05/24 at 3:50 P.M. with the Director of Nursing (DON) confirmed the investigation had no other staff interviews or resident interviews as they had no involvement. The DON also confirmed the investigation provided no specifics on the date the suspected perpetrator (Resident #100) was in the facility to get her belongs post discharge and confirmed Resident #65's report with the visitor logs. The DON confirmed the statement did not contain how much money was reported as missing and any steps with law enforcement or with the bank to get any lost money returned, including assisting Resident #65 with contacting the bank and looking at her online banking or review of banking statement for when money went missing. The DON confirmed the date listed on the SRI was just the date the resident had reported the concern to staff. The DON also confirmed facility had no evidence of Resident #65's representative being contacted so they could assist in getting residents money situated with her bank. Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, not dated revealed the following: A. Investigate Once the Administrator and ODH are notified, an investigation of the allegation violation will be conducted. 1. Timeframe for investigation. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (e.g., quantifying amounts misappropriated if accountant needs more time). 2. Investigation protocol. The person investigating the incident should generally take the following actions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 6 of 16 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 02/07/2024 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 0610 a. Level of Harm - Minimal harm or potential for actual harm Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. Residents Affected - Some i. If there are no direct witnesses, then the interviews may be expanded. [For example, consider interviews with all employees on the shift or the unit, as appropriate, as well as other residents on the unit.] For Injuries of Unknown Source, the investigation may generally involve talking with staff working on both the shift on duty when the injury was discovered and prior shifts as well. ii. If the allegation involves abuse/neglect, interview other residents, as appropriate, to determine if they may have been affected by the accused staff member or resident. b. Interview other health care professionals, as appropriate (e.g., Social Worker, physician/nurse practitioner, etc.) and document all interviews. c. Review all relevant medical reports/records, as applicable. d. If the accused is an employee, then review his/her employment records. 3. Documentation. Evidence of the investigation should be documented in accordance with Quality Assurance (QA) protocols. 4. Reach a conclusion. After completion of the investigation, the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated or unsubstantiated. The Administrator will determine if modifications to existing policies and procedures (or new policies and procedures) are needed to prevent similar incidents or injuries from occurring in the future in accordance with its QAPI Plan. The QA investigative materials will be reviewed by the QA Committee in accordance with the facility QAPI Plan. The QA Committee will take all actions deemed necessary based upon their review. This deficiency represents non-compliance investigated under Complaint Numbers OH00149981, OH00150001 and OH00150405. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 7 of 16 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 02/07/2024 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews and staff interviews, the facility failed to ensure resident's maintained quality of life while in COVID-19 isolation. This affected Residents #34 and #35 of two review for COVID-19 isolation. The facility identified seven residents (#3, #34, #35, #50, #59, #69) with COVID-19 positive diagnosis. Facility census was 76. Residents Affected - Few Findings include 1. Review of the medical record for the Resident #34 revealed an admission date of 10/24/23. Diagnoses included chronic obstructive pulmonary disease, COVID-19, respiratory failure with hypoxia, diabetes, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and required partial to moderate assistance for lower body dressing and hygiene. Review the progress note dated 01/31/24 revealed Resident #34 tested positive for COVID-19 and was placed in isolation. Physician order dated 02/02/24 revealed an order for the resident to remain on isolation precautions until 02/10/24. 2. Review of the medical record for the Resident #35 revealed an admission date of 09/14/21. Diagnoses included COVID-19, chronic pulmonary disease, chronic kidney disease, cervical cancer, pelvic cancer, Colostomy, personality disorder and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact and required substantial maximum assistance for personal hygiene. Review the progress note dated 01/29/24 revealed Resident #35 tested positive for COVID-19. Review of physician orders for 01/30/24 revealed an order for the resident to remain in isolation from 01/29/24 to 02/08/24 for COVID-19 positive test result. Observation on 02/05/24 at 10:30 A.M. revealed Activities Aide #220 walked down the hall and provided the daily chronicle along with snacks and drinks. The activity aide skipped Resident #34 and #35's (roommates) room and continued down the remainder of the hallway. Interview and observation on 02/05/24 at 10:46 A.M. with Resident #34 and #35 revealed concerns related to care and COVID-19 status. The resident's room was dirty with a three foot by two-foot section next to Resident #35's bed of crumbs on the floor and a spilled substance on the floor that Resident #35 reported as beet juice. Resident #34 and #35 also had three bedside trash cans and a bathroom trash can that were overflowing with trash and an additional bag that was tied up and placed against the wall. Staff were to place all Personal Protective Equipment (PPE) in the bedside trash cans, which were observed with PPE items that had fallen on the floor, including gowns and gloves. Resident #35 revealed staff had not cleaned their room all weekend and stated she felt they were being treated like leppers (a person with leprosy) as staff do not offer drinks, activities, or housekeeping services while they were in quarantine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 8 of 16 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 02/07/2024 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 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/05/24 at 11:19 A.M. with Activity Aide (AA) #220 revealed she was instructed by a previous Director of Nursing not to enter any COVID-19 positive rooms. AA #220 revealed she placed the daily chronical and a few bags of snacks outside the room on the isolation cart for staff to carry in the next time they enter. AA #220 confirmed she was also providing drinks (water, coffee, hot chocolate and tea) and confirmed no drinks or snack choices were offered. AA #220 acknowledged all residents, regardless of their isolation status, should receive the same level of care as other residents no on isolation. Interview and observation on 02/05/24 11:45 A.M. with Housekeeping Supervisor (HS) #205 confirmed Resident #34 and #35 had three bedroom trash cans and a bathroom trash can overflowing with trash and a tied up bag on the floor against the wall. Resident #34 and #35 returned from their isolation smoke break and spoke with HS #205 and reported no one had been in their room in several days and there was lots of trash, crumbs, and a spill on the floor from end of last week. HS #205 informed the residents she would speak with the staff on duty, as they should have received housekeeping services throughout the weekend. HS #205 also revealed nursing staff can and should also be removing trash that is obvious or overflowing. Interview on 02/06/24 at 4:00 P.M. with the Director of Nursing revealed residents, regardless of isolation status, should be provided with the same housekeeping services, activities, and snacks as residents not in isolation status. This deficiency represents non-compliance investigated under Complaint Number OH00150788. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 9 of 16 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 02/07/2024 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to ensure showers were offered twice weekly according to resident preference. This affected three (Residents #3, #35, and #55) of three reviewed for showers. Facility census was 76. Residents Affected - Few Findings include 1. Review of the medical record for Resident #3 revealed an admission date of 11/11/22. Diagnoses included chronic obstructive pulmonary disease, COVID-19, diabetes, acute respiratory failure, bipolar disorder, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and required partial moderate assistance with ambulation and activities of daily living. Review of the care plan dated 02/05/24 revealed the resident required assistance of one staff for bathing. Review of the shower sheets from 12/05/23 to 02/05/24 revealed showers were only offered on 12/11/23, 12/14/23, 01/19/24, and 01/29/24. Interview and observation on 02/05/24 at 11:35 A.M. with Resident #3 revealed the resident would like two showers weekly and they are not being offered consistently. The resident's hair appeared greasy and unwashed. 2. Review of the medical record for the Resident #35 revealed an admission date of 09/14/21. Diagnoses included COVID-19, chronic pulmonary disease, chronic kidney disease, cervical cancer, pelvic cancer, Colostomy, personality disorder and edema. Review of the MDS assessment dated [DATE] revealed Resident #35 was cognitively intact and required substantial maximum assistance for personal hygiene. Review of the plan of care dated 01/20/24 revealed Resident #35 required extensive assist for activities of daily living care. Review of the shower sheets from 12/05/23 to 02/05/24 revealed showers were only offered on 11/29/23, 12/20/23, and 12/26/24. Interview and observation on 02/06/24 at 11:35 A.M. with Resident #35 revealed the resident preferred to get her hair washed in the beauty salon which staff have done instead of giving her a shower. She revealed staff do not consistently offer or assist with washing her hair. The residents hair was pulled back and appeared to be unwashed. 3. Review of the medical record for the Resident #55 revealed an admission date of 09/05/23. Diagnoses included osteomyelitis of left foot and ankle, anorexia, dementia without behaviors, cognitive communication deficit, traumatic amputation of left, and vascular disease. Review of the MDS assessment dated [DATE] revealed Resident #55 was cognitively impaired and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 10 of 16 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 02/07/2024 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 0677 required two person assistance for bed mobility and physical assistance with bathing. Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated 12/23/23 revealed the resident had an Activities of Daily Living (ADL) self-care deficit requiring extensive assistance with ADL care and mobility. Interventions included resident preference to be bedfast most of the day and to encourage and accept to participate and accept staff assistance with bathing. Residents Affected - Few Review of the shower sheets from 12/05/23 to 02/05/24 revealed showers were only offered on 12/28/23, 01/05/24, and 01/28/24. Interview on 02/06/24 at 4:50 P.M. with Resident #55's family revealed the resident had not been receiving many showers. Interview on 02/06/24 at 11:46 A.M. with the Director of Nursing (DON) revealed showers should be offered twice weekly or upon resident request. She also confirmed staff should be documenting all attempts and marking whether a shower was completed or refused. The DON confirmed the facility was unable to provide additional evidence of showers being completed for Residents #3, #35, and #55 and verified lack of shower documentation. Review of facility policy titled, Bathing Policy, dated 08/2023, revealed residents had the option to take a bath or shower as often as they would like and choose the time of day to have it completed. This deficiency represents non-compliance investigated under Complaint Number OH00150788. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 11 of 16 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 02/07/2024 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 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 resident representative interview, staff interviews, and record review, facility failed to ensure dietitian recommendations were followed to maintain a resident's nutrition status. This affected one (Resident #55) of three reviewed for nutrition. Resident census was 76. Residents Affected - Few Findings include Review of the medical record for Resident #55 revealed an admission date of 09/05/23. Diagnoses included osteomyelitis of left foot and ankle, anorexia, dementia without behaviors, cognitive communication deficit, traumatic amputation of left foot and vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired and required two person assistance for bed mobility. Review of the care plan dated 12/23/23 revealed the resident was at risk of potential nutritional problem related to osteomyelitis with interventions to administer medications as ordered, monitor for signs of malnutrition and weight loss, obtain labs and diagnostic work as ordered and report to physician, provide diet as ordered, and dietician to monitor weight. Review of the progress note dated 09/07/23 revealed Resident #55's oral intake was 59-100% of his meals. It stated the resident used dentures and was at risk of malnutrition due to several comorbidities. Progress note dated 10/17/23 revealed no weight issues or losses but a supplement was added for wound healing (protein liquid 30 ml daily). Progress note dated 11/07/23 revealed Resident #55 had an unplanned significant weight change of 9.9% in one month. It stated the resident ate 50-75% at most meals. Resident #55 reported decreased appetite and denied problems with chewing or swallowing. Dietician recommendation to liberalize diet to regular and start a house supplement 240 milliliters (ml) and monitor weekly weights. Progress note dated 11/28/23 revealed the resident consumed 75% of boost breeze supplements and was agreeable to try the frozen nutritional supplement. Dietician recommendation for 237 ml Boost Breeze twice daily and a frozen nutritional supplement 120 ml twice daily. Progress note dated 12/19/23 revealed a second large weight loss of 10.7% in 30 days and family was discussing hospice care. Resident #55 reported he enjoyed the meals but did not like feeling full. Remeron was started 12/04/23 and the resident was on an antibiotic which may be altering his weight. The dietician started a new supplement house shake and wanted staff to continue to monitor weekly weights. Progress note dated 01/30/23 revealed the dietician requested a reweigh from additional weight loss on 01/27/24. Review of resident weights revealed the following: 09/05/23 - 163.0 pounds (lbs) 09/17/23 - 164.2 lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 12 of 16 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 02/07/2024 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 0692 10/08/23 - 162.0 lbs Level of Harm - Minimal harm or potential for actual harm 10/19/23 - 163.8 lbs Residents Affected - Few 11/03/23 - 146.0 lbs 11/22/23 - 144.2 lbs 11/28/23 - 144.2 lbs 12/12/23 - 128.8 lbs 12/12/23 - 128.8 lbs 12/19/23 - 128.0 lbs 01/01/24 - 126.2 lbs 01/27/24 - 118.1 lbs Weekly weights were missed the week of 11/12/23, 12/03/23, 12/24/23, 01/07/24, 01/14/24, and 01/21/23. Interview on 02/06/24 at 4:50 P.M. with Resident #55's family revealed the resident had lost a significant amount of weight and she reported concerns the facility was not monitoring weight appropriately. Interview on 02/06/24 at 1:58 P.M. with the Director of Nursing (DON) confirmed the facility did not have evidence of additional weights and confirmed weekly weights were not completed as recommended by the dietician. The DON confirmed she and the Assistant DON should review the recommendations and ensure orders are in place for supplements, diet changes, and obtaining weights. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 13 of 16 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 02/07/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Interview on 02/06/24 at 3:20 P.M. with Dietician #400 revealed she had issues with getting weekly weights from facility staff for her to review. She revealed weekly weights should be done the first month of admission and after significant weight losses as recommended. She revealed she had recommended weekly weights for Resident #55 due to unexplained weight loss to try and address smaller increments instead of 20-pound weight loss at once. Residents Affected - Few Review of the facility policy titled, Immediate Temporary Interventions for Unintended Significant Weight Loss, dated 2021, revealed individuals with unintended significant weight loss shall have immediate interventions put in place. The dietician will review weights monthly or more often as needed and assess nutritional status. The policy stated the dietician would determine a monitoring system to evaluate the interventions including weekly weights. This was an incidental finding over the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 14 of 16 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 02/07/2024 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 observations, staff interview, resident interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn when staff entered a COVID-19 positive rooms. This affected two (Residents #34 and #35) of three reviewed for COVID-19. Additionally, the facility failed to complete contact tracing during a COVID-19 outbreak. This had the potential to affect all residents residing in the facility. Facility census was 76. Residents Affected - Many Findings include 1. Review of the medical record for Resident #34 revealed an admission date of 10/24/23. Diagnoses included chronic obstructive pulmonary disease, COVID-19, respiratory failure with hypoxia, diabetes, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and required partial to moderate assistance for lower body dressing and hygiene. Review the progress note dated 01/31/24 revealed the resident tested positive for COVID-19 and was placed in isolation. Physician order dated 02/02/24 revealed an order for the resident to remain on isolation precautions until 02/10/24. 2. Review of the medical record for Resident #35 revealed an admission date of 09/14/21. Diagnoses included COVID-19, chronic pulmonary disease, chronic kidney disease, cervical cancer, pelvic cancer, Colostomy, personality disorder and edema. Review of the MDS assessment dated [DATE] revealed Resident #35 was cognitively intact and required substantial maximum assistance for personal hygiene. Review the progress note dated 01/29/24 revealed Resident #35 tested positive for COVID-19. Review of physician orders for 01/30/24 revealed an order for the resident to remain in isolation from 01/29/24 to 02/08/24 for COVID-19 positive test result. Interview on 02/05/24 at 10:46 A.M. with Resident #34 and #35 (roommates) revealed staff were not always wearing PPE and when they did it, was not consistent, stating sometimes they wear just a mask, and night staff don't even wear that. Observation and interview on 02/05/24 at 12:12 P.M. with State Tested Nursing Aide (STNA) #208 and Housekeeping Staff #230 confirmed no face shields were present in the isolation cart and housekeeping staff revealed they can wear goggles or add side guards to their glasses. STNA #208 confirmed she was not wearing approved eye protection and revealed she had her eye-glasses on and had a guard for it over there while pointing down the hall. STNA #208 confirmed she was in a COVID-19 positive room without the guards and had no explanation or reasoning for it. Housekeeping Staff #230 confirmed signage posted on the door indicated face shields or goggles were to be used for eye protection. Review of the signage posted on resident rooms with COVID-19 revealed pictures of PPE and how it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 15 of 16 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 02/07/2024 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 - Many should be worn properly and a list that states, STOP, before entering wear N-95, gown, face shield/goggles and gloves. Review of facility policy titled, COVID+ Units and COVID-19 Observation (Quarantine), dated 05/2023, revealed a resident with suspected COVID-19 should be in a room with precautions identified outside the room and staff MUST wear an N-95, eye protection that covers the front and sides of the face, gloves, and a gown when caring for residents in these rooms. 3. Review of the Long-Term Care (LTC) Respiratory Surveillance Line List revealed 12 residents tested positive for COVID-19 and nine staff had tested positive for COVID-19 from 12/01/23 to 02/05/24. The facility did not provide any evidence of contact tracing for the COVID-19 positive staff and resident cases. Interview on 02/06/24 at 11:00 A.M. with Corporate Administrator #210 and the Director of Nursing (DON) verified there was no evidence to show contact tracing had been completed for COVID-19 cases from 12/01/23 to 02/04/24. Interview on 02/06/24 at 11:46 A.M. with the DON revealed the Infection Control Designee had just started and was trying to piece the COVID-19 outbreak together. The DON revealed she was newer to the facility and was unsure who was tracking COVID infections prior to her starting, but the responsibility would be moving to the Assistant Director of Nursing. Review of facility policy titled, Infectious Disease, dated 09/2022, revealed the facility would compete contract tracing for all confirmed or suspected cases of COVID-19. Review of facility policy titled, LTC Respiratory Surveillance Line List procedure, dated 03/12/19, revealed the procedure provides a template for data collection for residents and staff during a respiratory illness or outbreak. Information gathered should be used to build a case definition to determine the outbreak or illness and support monitoring and identification of new cases. This deficiency represents non-compliance investigated under Complaint Number OH00150639. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 16 of 16