Inspection·September 30, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few unit would benefit the resident due to a smaller unit that allowed for staff interventions Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M. Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called Emergency Medical Services (EMS). LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written stated dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of EMS report dated 09/23/25 noted at 9:41 P.M. and EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be 1:1 with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 was with no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. 911 returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled a CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. the received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN#400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and strangulation. Narrative notes documented when the officer arrived on scene he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few in physical harm. The policy defines serious bodily injury as an injury involving extreme physical pain; involving substantial risk of death. The policy defines willful to mean the individual must have acted deliberately. This deficiency represents non-compliance investigated under Master Complaint Number 2627173 and Complaint Number 2626970, Complaint Number 2626838, Complaint Number 2626237. Review of the medical record revealed Resident #29 admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder. Review of the resident census revealed Resident #29 was initially admitted to the secured dementia unit and then moved to the secured second floor behavior unit on 07/17/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with clear speech, usually understood and understands others, moderate cognitive impairment, no recorded behaviors, no range of motion impairment, and independent with ambulation. Review of the resident's care plan dated 07/25/25 revealed the nursing plan of care was revised to address Resident #29's cognitive loss/disorientation/impaired judgement related to diagnosis of schizophrenia. Interventions included: Follow doctor's orders for appropriate treatment, review the medication regimen with the physician to assess and rule out possible side effects or contraindications related to medications or food products, verbalize you will help him/her Stay in control, assure the resident is protected, safe, and secure and in a protected environment. On 08/21/25 Resident #29 was evaluated by psychiatry services. Resident #29 was documented to be pleasant, calm and engaged throughout the entire evaluation. Psychoactive medications were reviewed, and no behaviors were documented. Review of Resident #29 medical record lacked documentation indicating he exhibited aggressive behaviors towards staff or residents while residing at the facility. Review of the resident census revealed Resident #29 was returned to the dementia unit on 09/05/25. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included major depression, bipolar disorder, muscle weakness, cognitive communication deficit, insomnia, anxiety disorder, polyneuropathy, and anemia. Resident #53 resided on the secured dementia unit since 01/24/25. Review of the MDS assessment dated [DATE] revealed Resident #53 had clear speech, usually understood and understands, severe cognitive impairment, no recorded behaviors, and was independently ambulatory. On 08/28/25 a quarterly secure unit admission assessment noted Resident #53 to be appropriate for the dementia unit due to a mental health condition. The unit would benefit the resident due to a smaller unit that allowed for staff intervention. Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M., Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called EMS. LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written statement dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of the EMS report dated 09/23/25 noted at 9:41 P.M. an EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be one-on-one with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 had no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple, and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased , and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. Nine-one-one (911) returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. they received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN #400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365747 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 365747 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Waterville 555 Anthony Wayne Trail Waterville, OH 43566 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete strangulation. Narrative notes documented when the officer arrived on scene, he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded, I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded, Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting in physical harm. The policy defines serious bodily injury as an injury involving extreme ph Event ID: Facility ID: 365747 If continuation sheet Page 8 of 8