Inspection·March 25, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 05/12/23 at 10:45 A.M. The DON stated Resident #15 was dependent on staff for activities of daily and was non-verbal, a nurse would need to attend the telehealth visit in the room to provide clinical information, obtain any orders provided during the visit and documentation of the visit would be documented in Resident #15's medical record. Interview with Regional Nurse #401 on 03/25/24 at 2:00 P.M. verified Resident #15 did not have any documented record of Resident #15 attending the scheduled neurological physician's appointment on 04/17/23 at 12:45 P.M. or the telehealth appointment with neurological physician on 05/12/23 at 10:45 A.M. The neurological physician's office verified Resident #15 has not attended his scheduled appointments. Regional Nurse #401 stated the facility was unaware Resident #15 missed these appointments and did not have a policy regarding transportation to outside physician services. This deficiency represents non-compliance investigated under Complaint Number OH00152002 and Complaint Number OH00152143. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 2 of 8 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 03/25/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, and review of the facility policy, the facility failed to provide a safe environment that was free from accident hazards and failed to complete a thorough investigation into a resident's fall. This resulted in Actual Harm for one resident when on 03/04/24, Resident #04 was attempting to enter the main entrance of the facility with an uneven surface transition causing Resident #04 to fall backwards out of his wheelchair sustaining a subdural hematoma (serious condition where the blood collected between the skull and the surface of the brain), retrolisthesis (backward slippage of one vertebral body with respect to the subjacent vertebra) of cervical vertebrae and a scalp laceration requiring three sutures. Additionally, a second resident (Resident #02) was placed at risk for the potential for more than minimal harm that was not actual harm when the cognitively impaired resident was not provided with adequate supervision when he was let outside the secured facility by another resident in the middle of the night and fell behind an emergency squad truck. This affected two (#04 and #02) of three residents reviewed for falls and accidents. The facility census was 82. Finding include: 1. Review of the medical record for Resident #04 revealed an admission date of 12/11/23. Diagnoses included end stage renal disease with hemodialysis, atrial fibrillation, hepatic encephalopathy, cognitive communication deficit, cirrhosis of the liver, muscle weakness, congestive heart failure, and right above the knee amputation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Resident #04 required partial/moderate assistance from staff for shower/bathing and upper body dressing, and substantial/maximal assistance from staff for lower body dressing. Resident #04 utilized a manual wheelchair, had no behaviors, no rejection of care, or wandering during the review period. Review of the plan of care dated 01/25/24 revealed Resident #04 was at risk for increased falls with or without injury, related to right above the knee amputation, dialysis, chronic congestive heart disease, cirrhosis of the liver, neuropathy, and non-compliance with care needs. Interventions included keeping the resident's call light within reach, Dycem to seat of wheelchair, commonly used items within reach, and to encourage the resident to ask for help before opening the door for another resident. Resident #04 was at risk for impaired communication, usually understood and understands others related to respiratory failure, encephalopathy, depression, hypotension, and atrial fabulation. Interventions included ensuring or providing a safe environment. Review of the fall risk evaluation assessment on 03/01/24 revealed Resident #04 was assessed to be at risk for falls. Review of the progress notes dated 03/04/24 at 7:57 P.M. revealed Resident #04 was sent to the hospital following a fall outside. Resident #04 hit the back of his head and was bleeding a lot. Staff called emergency 9-1-1 immediately and responsible parties were notified. Review of the incident report dated 03/04/24 revealed Resident #04 was on the ground and bleeding outside in front of the building. The nurse assessed Resident #04 and emergency services transported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 3 of 8 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 03/25/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Resident #04 to the hospital. No witness statements were provided in the report. The incident report did not identify an environmental hazard where Resident #04 fell outside. There was also no statement from Resident #04 when he returned to the facility on [DATE]. The incident report did not state what was occurring at the time of the fall; however, the new intervention was to educate Resident #04 to not hold onto a powered wheelchair and allow another resident's powered wheelchair to pull him forward. Review of the hospital records for 03/04/24 to 03/07/24 revealed Resident #04 received treatment for traumatic subdural hematoma, retrolisthesis of the cervical five and six vertebrae, and a 1.5-centimeter (cm) laceration to posterior scalp requiring three staples from a fall out of a wheelchair. Resident #04 received treatment for his injuries and was discharged back to the facility on [DATE]. Interview with Resident #04 on 03/19/24 at 7:45 A.M. revealed he went outside to get some fresh air on 03/04/24 in the evening and he talked with other residents in the parking lot area like he had done in the past. At some point, he started to head back to the main entrance when another resident (Resident #50) in an electric wheelchair told him to grab a hold to the back of her wheelchair. Resident #50 proceeded to pull him up to the front entrance where the overhang was located. Once they got to the front door area, there was a transition from pavement to concrete that has a rough transition. Resident #04 explained the bump caused his wheelchair to flip backwards, hitting the back of his head on the pavement. Resident #04 stated Resident #50 who was in the electric wheelchair went in immediately and got help. The nurse held something to the back of his head, and he was transported to the hospital. Interview with Resident #50 on 03/19/24 at 8:35 A.M. revealed on 03/04/24, she attempted to assist Resident #04 from the parking lot area up to the front of the building because of all the potholes on the driveway and the sidewalk being hazardous. Resident #50 stated she had Resident #04 hold onto her electric wheelchair to assist him back to the front of the building, but once she got to the hump at the front of the building (at the covered entrance) she heard and felt Resident #04 get stuck. As she turned her wheelchair around, she saw Resident #04's wheelchair had flipped, and Resident #04 was lying on his back with blood everywhere. Resident #50 went directly into the facility, yelled for help, a nurse came, and Resident #04 went to the hospital. Resident #50 stated she has resided at the facility since July 2023 (approximately eight months) and the parking lot, the entry bump, and the sidewalk have been hazards since she moved in. Resident #50 stated she had told the previous administration and maintenance staff about it, and nothing has been repaired. Resident #50 stated many residents go out in the parking lot area, but they cannot use the sidewalk because it was falling apart and they must avoid all the bumps and potholes in the driveway/parking lot area causing it to be hazardous to navigate. Interview and observations of the main entrance, parking lot/driveway and sidewalk on 03/14/24 at 10:45 A.M. with Maintenance Director #115 revealed there were areas of hazards on the sidewalk marked with six large orange cones. Maintenance Director #115 stated some areas of repair had been completed, and some areas still needed to be repaired. The facility was working towards fixing along with the sidewalk's broken concrete but was hindered by weather. Maintenance Director #115 verified there were cracking edges/missing pieces of concrete at the sidewalk areas leading from the entrance to the parking lot. Observation of the covered front entrance revealed there were approximately two-to-three-inch differentiation in surface transitions between the concrete and pavement at the main entrance under the covered front entrance, and several areas of potholes in the driveway from the front covered entrance to the side parking lot of the facility. Maintenance Director #115 verified residents often use the parking lot throughout the day to get fresh air. Residents were observed in the side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 4 of 8 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 03/25/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few parking lot. Maintenance Director #115 verified the differentiation in surface transitions. Maintenance Director #115 stated he had assessed the parking lot/sidewalk and transitioning areas at the main entrance, and he identified they were areas of concern for fall/trip hazards. Maintenance Director #115 verified the height of the transition from pavement to concrete at the main entry was an area of hazard that could have contributed towards Resident #04's fall on 03/04/24. Interview and observation with Director of Nursing (DON) on 03/18/24 at 2:30 P.M. verified the location of Resident #04's fall on 03/04/24. The DON verified the transitional area at the main entrance, under the covered front entrance at the transition between the concrete and the pavement area was an accident hazard and could have contributed to Resident #04's fall on 03/04/24. The DON verified the facility's incident report did not include the environmental hazard which could have contributed to Resident #04's fall and the facility did not obtain witness statements for the incident report. Review of the facility policy titled Falls and Fall Risk Managing, with a reviewed date of 08/2023, revealed staff will identify interventions related to the resident's risks. The environmental factors that contribute to the risk of falls include obstacles in the footpath. 2. Closed medical record review for Resident #02 revealed an admission date of 02/20/24. Diagnoses included dementia, type II diabetes mellitus with neuropathy, Parkinson's disease, and seizures. Resident #02 was discharged home with his family on 03/05/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and did not wander. Resident #02 required partial or moderate assistance from staff for toileting, bathing, and upper body dressing. Review of the care plan dated 02/20/24 revealed Resident #02 had impaired cognition function /dementia as evidence by impaired thought processes and history of multiple falls. Interventions included to provide supervision/assistance with decision making. Review of the elopement risk assessment dated [DATE] revealed Resident #02 was not at risk for elopement. Review of the fall risk assessment dated [DATE] revealed Resident #02 was at a fall risk. Review of Resident #02's incident report for 03/03/24 at 3:40 A.M. revealed a resident (#45) let Resident #02 out of the building (by entering the facility's door alarm code) because Resident #02 wanted to find his truck. Resident #02 had an unwitnessed fall outside in the front of the building. Resident #02 sustained no injuries. The resident who witnessed the fall (#45) would not provide a witness statement. There was no environmental hazards that contributed Resident #02's fall. The facility's conclusion after speaking with EMS was they felt Resident #02 may have tried to climb into the squad truck because Resident #02 thought it was his truck and fell. Review of Resident #02's physician order dated 03/03/24 revealed an order for Accutech (wanderguard) to his right ankle and check placement every shift. Interview on 03/14/24 at 9:00 A.M. with Maintenance Director #115 stated the facility's door alarm codes were changed routinely and on an as needed basis for safety concern of a non-staff member knowing the code. The front door alarm was turned off at 6:00 A.M. and was turned back on at 5:30 P.M. Maintenance Director #115 stated the facility did not have a policy on how often the door alarm codes were to be changed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 5 of 8 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 03/25/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few Interview with the Director of Nursing (DON) on 03/18/24 at 10:30 A.M. revealed an investigation had been conducted regarding Resident #02's exit and subsequent fall in the A.M. on 03/03/24. At approximately 3:30 A.M. on 03/03/24, emergency services were called for another resident, and the squad was parked outside the front entrance. The emergency services team (EMS) had loaded the other resident into the squad, and were about to leave when they heard yelling. EMS got out of the squad, walked to the back of the squad, and found Resident #02 lying on the ground behind the squad with another resident (#45). EMS called the building to alert staff of Resident #02 and placed him on the bench outside of the building and left for the emergency department with the other resident. The staff rushed outside to find Resident #02 sitting on the bench with no injuries. Resident #02 was immediately placed on one-on-one supervision with staff and a wanderguard was placed. During the facility's investigation, Resident #45 verbally confessed to letting Resident #02 outside with him after putting in the door alarm code so Resident #02 could go see the truck. There was an unknown amount of time had gone by since the door codes had been changed and verified staff members were the only ones that were to have the door alarm codes. This deficiency represents non-compliance investigated under Complaint Number OH00152002 and Complaint Number OH00151683. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 6 of 8 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 03/25/2024 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure Resident #15 was provided with dental services. This affected one (Residents #15) of three residents who were reviewed for dental services. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 03/20/23. Diagnoses included acute respiratory failure, tracheostomy, cerebrospinal fluid drainage device, dysphagia, anemia, and transient ischemic attack. Review of Resident #15's admission agreement dated 03/20/23 revealed the responsible party for Resident #15 signed an authorization form for Resident #15 to be provided with dental services. Review of Resident #15's care plan dated 04/03/23 revealed Resident #15 had the potential for oral/dental health problems having natural teeth in poor condition related to anemia, dysphagia, fluids/nutrition provided by gastric tube and tracheostomy. Individualized interventions included to coordinate arrangements for dental care and transportation and to monitor/document/report to medical doctor as needed of signs or symptoms of oral or dental problems. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was unable to complete a cognitive assessment and Resident #15 was dependent on staff for eating, oral care, and personal hygiene. Resident #15 had natural teeth, no abnormal mouth tissues, and no mouth or facial pain. Resident #15's medical record did not have any physician orders for routine dental services or any records Resident #15 was seen by the dentist. Interview with State Tested Nursing Aide (STNA) #333 on 03/21/24 at 11:30 A.M. revealed Resident #15 was dependent for mouthcare and had natural teeth. STNA #333 stated while providing mouth care, she observed Resident #15 to have bad breath and was not sure the last time Resident #15 had seen the dentist. Interview with the Director of Nursing on 03/21/24 at 3:00 P.M. revealed dental services were provided for residents who have signed authorization requesting services. The residents were put on a dental list to be seen for routine prevention and treatment associated with dental/ mouth issues if clinically indicated. Interview with Respiratory Therapist #322 on 03/25/24 at 8:00 A.M. revealed the residents with a tracheostomy, ventilator, and/or who were oxygen dependent need to be provided with routine oral care and dental care because of the high risk for unrecognized dental or mouth infections leading to pneumonia or air way complications. Interview with Regional Nurse #401 on 03/25/24 at 2:00 P.M. verified Resident #15 did not have any documented record of dental services being provided. This deficiency represents non-compliance investigated under Complaint Number OH00152143. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 7 of 8 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 03/25/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, resident and staff interviews, the facility failed to provide a safe outside environment for the residents. This affected two (#04 and #50) of two residents reviewed for the physical environment and had the had the potential to affect all 82 residents residing in the facility. Finding include: Observation on 03/14/24 at 6:28 A.M. revealed there was an identified resident in a wheelchair with a neon yellow shirt on in the facility's parking lot. When you drive into the facility's property there is a driveway with pot holes and there was a parking lot to the left of the building. There several pot holes in the driveway and parking lot. There were orange cones noted on the sidewalk of the facility. Interview and observations of the main entrance, parking lot/driveway and sidewalk on 03/14/24 at 10:45 A.M. with Maintenance Director #115 revealed there were areas of hazards on the sidewalk marked with six large orange cones. Maintenance Director #115 stated some areas of repair had been completed, and some areas still needed to be repaired. The facility was working towards fixing along with the sidewalk's broken concrete but was hindered by weather. Maintenance Director #115 verified there were cracking edges/missing pieces of concrete at the sidewalk areas leading from the entrance to the parking lot. Observation of the covered front entrance revealed there were approximately two-to-three-inch differentiation in surface transitions between the concrete and pavement at the main entrance under the covered front entrance, and several areas of potholes in the driveway from the front covered entrance to the side parking lot of the facility. Maintenance Director #115 verified residents often use the parking lot throughout the day to get fresh air. Residents were observed in the side parking lot. Maintenance Director #115 verified the differentiation in surface transitions. Interview with Resident #04 on 03/19/24 at 7:45 A.M. stated the area by the front entrance to the facility had a transition from pavement to concrete that has a rough transition. Resident #04 explained the bump in the pavement caused his wheelchair to flip backwards. Interview with Resident #50 on 03/19/24 at 8:35 A.M. revealed she has resided at the facility since July 2023 (approximately eight months) and the parking lot, the entry bump, and the sidewalk have been hazards since she moved in. Resident #50 stated she had told the previous administration and maintenance staff about it, and nothing has been repaired. Resident #50 stated many residents go out in the parking lot area, but they cannot use the sidewalk because it was falling apart and they must avoid all the bumps and potholes in the driveway/parking lot area causing it to be hazardous to navigate. This was an incidental finding discovered during the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 8 of 8