Health inspection·March 23, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #30) nephrologist of laboratory test results as ordered by the physician. This affected one (Resident #30) of one reviewed for notification of change. The facility census was 59. Findings Include: Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), hyperkalemia, Type II Diabetes Mellitus, and hypertensive chronic kidney disease with end stage renal disease. Review of lab orders revealed Resident #30 had the following lab orders: Complete Blood Count (CBC), Ferritin, Iron Pan, Protein total random urine with creatinine, urinalysis with microscopic, Vitamin D, renal function panel, Parathyroid Hormone (PTH), Folate, and Vitamin B12 dated 11/18/22 with instructions to fax results to nephrologist and CBC, Ferritin, Iron Panel, PTH, protein total, random urine with creatinine, renal function panel, urinalysis with microscopic, Vitamin K, Vitamin D25 and Hyrdoxyzine dated 07/22/22 with instructions to fax results to nephrology. Review of the lab results dated 07/22/22 and 11/18/22 revealed there was no evidence results were faxed to the nephrologist as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of the progress notes dated from 07/01/22 through 12/01/22 revealed there was not any evidence Resident #30's nephrologist was notified of the resident's lab results from 07/22/22 or 11/18/22. Review of the plan of care revised on 11/18/21 revealed Resident #30 had renal insufficiency with interventions including monitor lab reports of electrolytes and report to physician. Interview on 03/15/23 at 3:09 P.M. with the Director of Nursing (DON) confirmed there was not any evidence Resident #30's nephrologist was notified of the resident's lab results as ordered on 07/22/22 or 11/18/22. Review of the facility policy, Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, revealed the policy stated, nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: whether the physician has requested to be notified as soon as a result is received, whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal results is problematic regardless of any other factors), and whether the resident/patient's clinical status is unclear or he/she has signs or symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 2 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) for individuals with mental disorders was accurate. This affected four (Resident #14, #16, #19 and #42) of four residents reviewed for preadmission screening. The census was 59. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Record review revealed Resident #16 is non-verbal, answers with shaking head yes/no, however at times doesn't reply with non-verbal gesture - he will just stare with no response. Review of the pre-admission screening and resident review (PASARR) did not indicate the diagnosis of schizophrenia added on 05/12/17 and was not updated. This was verified during interview with the Director of Nursing on 03/14/23 at 3:52 P.M. 2. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression, diabetes, and congestive heart failure (CHF). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was mildly impaired. He required extensive assistance of two plus staff members physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the PASARR dated 06/10/22 did not indicate the diagnosis of schizophrenia. On 07/25/22 the diagnosis of schizophrenia was added and the PASARR was not updated. This was verified during interview with the Director of Nursing on 03/14/23 at 3:52 P.M. 4. Review of Resident #14's medical record revealed an original admission date on 10/31/11 and readmission dates on 10/30/18 and 08/24/19. Medical diagnoses included schizoaffective disorder (05/01/18), unspecified psychosis (05/01/18), major depressive disorder (02/01/18), anxiety disorder (02/01/18), and obsessive-compulsive disorder (OCD) (02/01/18). Review of physician orders dated March 2023 revealed Resident #14 had the following order: Zoloft 50 milligrams (mg) with instructions to give one tablet daily for depression dated 06/24/21. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #14 required supervision with set up help only for most Activities of Daily Living (ADLs), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 3 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0644 except required extensive assistance from one staff for dressing. Level of Harm - Minimal harm or potential for actual harm Review of the plan of care dated 06/01/18 revealed Resident #14 had behavioral symptoms related to mood including watching inappropriate things on television. Interventions included monitor and document signs and symptoms of agitation and/or resisting what is asked of him. Resident #14 resisted care including refusing showers, dressing changes, and non-compliance with diet and had potential to be verbally aggressive. Interventions included administer medications as order and monitor/document side effects and effectiveness, monitor behaviors as needed and document observed behaviors and attempted interventions, and psychiatric consult as indicated. Resident #14 had impaired cognition related to schizophrenia. Interventions included monitor/document/report as needed any changes in cognitive function and administer medications as ordered. Resident #14 had a mood problem with interventions including monitor/document/report as needed any risk for harm to self, monitor/report to physician as needed acute episode feelings of depression, monitor/report mood to determine if problems seemed to be related to external causes, and monitor/report to physician as needed mood patterns and signs or symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Resident #14 was on antidepressant medication. Interventions included administer antidepressant medications as ordered by physician and document effectiveness every shift and observe/document/report as needed any adverse reactions to medication. Residents Affected - Some Review of the PASARR dated 05/10/18 revealed the screening included diagnoses of mood disorder, anxiety disorder, and other psychotic disorder. The screening did not include Resident #14's diagnosis of schizoaffective disorder and did not include resident's antidepressant medication. Interview on 03/14/23 at 3:57 P.M. with the Director of Nursing (DON) confirmed Resident #14's PASARR did not include the diagnosis of schizoaffective disorder or antidepressant medication and should have been updated. Review of the facility policy for Pre-admission Screening, undated, revealed the policy stated, if a patient/resident had an improvement or decline (significant change) in his/her condition, the nursing center was required to do another PASARR to evaluate for serious mental illness (SMI) or developmental disability (DD). This must be completed within 72 hours of the significant change. 3. Review of the medical record for Resident #19 revealed the resident was admitted on [DATE] with a medical diagnosis of Alzheimer's disease, post- traumatic stress disorder, dysphagia, dementia, depression, [NAME] insufficiency, polyosteoarthritis, peripheral vascular disease, apraxia, anxiety disorder. Review of PASARR for Resident #19 dated 06/10/22 revealed no serious mental illness was documented. Interview with the Director Of Nursing (DON) on 03/14/23 at 3:56 P.M. verified the PASARR dated 06/10/22 did not reflect the diagnosis of Alzheimer's; dementia; or any anti-depressant medication (Resident #19 is on sertraline for depression). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 4 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, policy review, and staff interview, the facility failed to ensure treatment orders were completed for residents with cardiac and blood pressure medical conditions. This affected two residents (#30 and #42) of five residents reviewed for unnecessary medications. The census was 59. Residents Affected - Few Findings include: 1. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression, diabetes, and congestive heart failure (CHF). Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed his cognition was mildly impaired. He required extensive assistance of two plus staff members physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the physician orders revealed an order dated 03/08/22 for daily weight, one time a day related to congestive heat failure (CHF). Review of the medical record revealed for January 2023, no weights were documented 01/03/23, 01/12/23, 01/13/23, 01/21/23 and 01/22/23. For February 2023, no weight for 02/10/23 and for March 2023 no weights for 03/04/23, 03/05/23, 03/07/23, 03/09/23, and 03/10/23. Review March 2023 physician orders revealed Lasix (diuretic) 40 milligrams (mg) one tablet by mouth one time a day for CHF and hold if BP (blood pressure) 90/60 or lower. Review of the medication administration record (MAR) for January 2023 revealed on 01/01/23 a blood pressure of 90/58 and on 01/19/23, 77/48 and Lasix 40 mg was still administered. For February 2023 blood pressure for 02/08/23- 86/56, 02/14/23- 88/56, 02/21/23- 89/63. For March 2023, blood pressure for 03/01/23- 88/58 and 03/15/23- 89/57. The Lasix was marked as administered and not held as per physician's orders. Interview on 03/16/23 at 10:00 A.M. with Licensed Practical Nurse (LPN) #149 verified the missing weights and Lasix administered outside of the parameters. 2. Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of physician orders dated March 2023 revealed Resident #30 had the following orders: Lasix 40 milligrams (mg) daily with instructions to hold for systolic blood pressure (SBP) less than 100 and give one tablet twice daily for hypertension for three days dated 03/03/23, Blood pressure every day shift dated 10/30/21, Metoprolol 50 mg with instructions to give one tablet by mouth two times a day and hold if SBP was less than 100 or heart rate (HR) was less than 60 and notify nurse practitioner dated 03/15/23. An additional physician order dated 12/28/22 to obtain the following labs was in place: obtain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 5 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and Comprehensive Metabolic Panel (CMP) one time only for wheezing and cough for two days. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated December 2022 revealed the lab order was marked as completed on 12/28/22. Review of the Medication Administration Record (MAR) dated January 2023 revealed Lasix medication was administered on 01/07/23 when Resident #30's blood pressure was 91/50, 01/12/23 with a blood pressure of 99/50, 01/13/23 with a blood pressure of 90/50, and 01/16/23 with a blood pressure of 87/52. Also, Metoprolol medication was administered on 01/15/23 with a heart rate of 56, 01/20/23 with a heart rate of 53, and 01/31/23 with a heart rate of 51. However, the Metoprolol medication was held on 01/07/23, 01/12/23, 01/13/23, 01/16/23, and 01/30/23 due to Resident #30's SBP being less than 100. Review of the MAR dated February 2023 revealed Lasix medication was administered to Resident #30 on 02/05/23 with a blood pressure of 85/50, 02/14/23 with a blood pressure of 86/53, 02/23/23 with a blood pressure of 80/53, and 02/24/23 with a blood pressure of 85/50. Also, Resident #30 was administered Metoprolol medication on 02/09/23 with a heart rate of 55 and 02/12/23 with a heart rate of 57. However, the Metoprolol medication was held on 02/05/23, 02/13/23, 02/14/23, 02/23/23, and 02/24/23 due to Resident #30's SBP being less than 100. Review of MAR dated March 2023 revealed Lasix medication was administered to Resident #30 on 03/06/23 with a blood pressure of 90/70. Metoprolol medication was administered on 03/07/23 with a SBP of 96/57. Review of the progress notes dated from 12/01/22 through 12/31/22 revealed there was no evidence of the labs being drawn or the lab results being received. Review of the progress notes dated from 01/01/2023 through 03/15/2023 revealed there was no evidence the physician or the nurse practitioner were notified of Resident #30's medication being held. Review of the plan of care dated 11/18/21 revealed Resident #30 had hypertension. Interventions included administer antihypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Interview on 03/15/23 at 3:05 P.M. with the Director of Nursing (DON) confirmed Resident #30 was administered Lasix and Metoprolol medications outside of parameters as ordered by the physician and there was not any evidence that the physician or the nurse practitioner were notified when Resident #30's medications were held. The DON also confirmed the labs ordered on 12/28/22 were not entered properly into the electronic medical record for Resident #30 and therefore, were not obtained as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 6 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Medications and Treatment Orders, undated, revealed the policy stated, parameters will be followed on medications when clinically indicated and ordered by physician or nurse practitioner (NP). Any time a medication is held due to parameter restrictions, physician or NP will be notified and conversation and clinical findings will be documented in resident's record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 7 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation revealed the facility failed to ensure pressure ulcer treatment and interventions were in place for two residents (#17 and #28) of four residents reviewed for pressure ulcers. The census was 59. Residents Affected - Few Findings included: 1. Review of Resident #28's medical record review revealed he was admitted to the facility on [DATE]. Diagnoses included psychosis, post traumatic stress disorder (PTSD), major depression, anxiety, anorexia, cerebral vascular accident with left sided hemiplegia and peripheral vascular disease. Review of Resident #28's significant change minimum data set (MDS) assessment dated [DATE] revealed his cognition was not intact. He required total dependence of two or more staff members physical assistance for bed mobility, transfers, and toilet use. He required extensive assistance of one staff member physical assistance for personal hygiene and dressing. Review of Resident #28's pressure ulcer risk assessment dated [DATE] revealed the resident was at moderate risk for the development of pressure ulcers. Review of Resident #28's physician orders revealed the following: on 10/17/19 pressure reduction cushion to wheelchair, on 10/28/20 encourage to turn and reposition frequently as tolerated to enhance skin integrity every shift for preventative skin care. Review of the plan of care dated 02/23/22 revealed Resident #28 had a potential for altered skin integrity related to occasional Incontinence, impaired mobility, varied appetite and intakes, Adult failure to thrive, history pressure ulcer, dry skin, prefers to be in bed will have intact skin, free of redness, blisters or discoloration by/through review date, moisture barrier as ordered to promote healthy skin, pressure reducing cushion to wheelchair; monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Right side assist bar to enhance bed mobility, remind/assist with turning and repositioning at regular intervals. Weekly skin assessment per nurse, notify physician/CNP of any indications of skin breakdown ,administer treatments if/as ordered and monitor for effectiveness, air mattress with bolsters to bed. Preventative treatments as ordered. Resident #28's plans of care revealed the resident will be free from further signs and symptoms of skin breakdown: redness, tenderness, discoloration, chafing, blisters, open areas. Review of the resident's medical record revealed Resident #28 had a shower sheet that identified redness on 02/06/23 then on 02/09/23 it almost presented as MASD (moisture associated skin damage). There was no evidence a treatment of the area was initiated. Interview on 03/15/23 at 10:47 A.M. with Licensed Practical Nurse (LPN) #149 verified Resident #28 had a shower sheet that identified redness on 02/06/23 and 02/09/23. LPN #149 verified there was no evidence a treatment was started. 2. Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fracture of the left femur, high blood pressure, rheumatoid arthritis, dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 8 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 anxiety and protein calorie malnutrition. Level of Harm - Minimal harm or potential for actual harm Review of the significant change MDS assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assistance of two or more staff members for bed mobility, transfers, and extensive assistance of one staff member physical assistance for dressing and personal hygiene. She required total dependence of two or more staff members for toilet use. An unstageable DTI (deep tissue injury) identified upon admission. Residents Affected - Few Review of the physician orders revealed the following: On 12/22/22- Turn and reposition every 2 hours as tolerated to enhance skin integrity, foam cushion to wheelchair, ultra foam mattress. On 02/14/23- Apply betadine topically to DTI on left heel every shift until healed every shift, and float heels every shift on pillow while in bed. On 02/26/23- Geri sleeves to bilateral arms everyday at all times and may remove for hygiene. On 03/02/23- Skin assessment every week on Thursday. Review of the plan of care dated 12/22/22 revealed Resident #17 was at risk for pressure ulcer development due to impaired and reduced mobility, incontinence and DTI (deep tissue injury) to left heel , DTI will resolve without complications, encourage and assist resident to turn and reposition every 2 hours when in bed, keep heels elevated off mattress, float heels on pillow to off set pressures to heels, keep skin clean and dry, protective mattress on bed and cushion in wheel chair, tubi grip to bilateral upper extremities for protection against bruising/skin tears, monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. Review of Resident #17's Pressure Ulcer Risk assessment dated [DATE] revealed she was at risk for developing pressure ulcers. Review of the measurements to the left heel revealed : On 02/14/23 left heel on admission, 1.2 cm by 1 cm On 02/22/23 left heel 1.2 cm by 1 cm On 03/01/23 left heel 0.5 cm by 0.5 cm On 03/08/23 left heel 0.2 cm by 0.2 cm On 03/15/23 left heel area healed Observations on 03/15/23 at 1:28 P.M. revealed Resident #17 in bed on her back with her feet not elevated on pillows. On 03/15/23 at 1:47 P.M. revealed Resident #17 remained in bed without her feet elevated on pillows. This was verified during interview at the time of the observation with the Director of Nursing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 9 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure respiratory equipment was stored appropriately to prevent infection. This affected one resident (#17) of two residents reviewed for respiratory care. The census was 59. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included fracture of the left femur, high blood pressure, rheumatoid arthritis, dementia, anxiety and protein calorie malnutrition. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired. She required extensive assistance of two or more staff members for bed mobility, transfers, and extensive assistance of one staff member physical assistance for dressing and personal hygiene. She required total dependence of two or more staff members for toilet use. Review of the physicians orders dated 01/26/23 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) (milligrams)MG/3 ML(milliliters) (Ipratropium-Albuterol) 3 ml inhale orally every six hours as needed for SOB (shortness of breath) related to asthma. Observations on 03/15/23 at 1:28 P.M. revealed the nebulizer mask and tubing laying on bedside stand uncovered. On 03/15/23 at 1:47 P.M. observation revealed the nebulizer mask and tubing remained on bed side table without being covered. This was verified during interview at the time of the observation with the Director of Nursing. On 03/15/23 at 3:07 P.M. observation revealed the nebulizer tubing and mask remain on bed side table uncovered. Review of the facility policy Hand Held Nebulizer (Facility) Policy not dated revealed when treatment is completed, rinse medication nebulizer cup with tap water and store at bedside on paper towel or in a plastic bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 10 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of a fall investigation, facility policy review, and staff interviews, the facility failed to provide effective pain management to Resident #23 following a fall on 05/21/22 that resulted in two fractured ribs. This affected one resident (#23) of one resident reviewed for pain management. The facility census was 59. Residents Affected - Few Actual Harm occurred to Resident #23 on 05/21/22 when the resident was not provided effective pain relief until being transferred to the hospital on [DATE] at 11:21 P.M. (nearly two days after the fall occurred) where subsequent additional treatment was provided to the resident for effective pain management. During the time period between the fall and the hospitalization the resident complained of increased pain, ineffective pain medication (Tylenol) and feeling fatigued due to an inability to sleep. Findings Include: Review of the medical record for Resident #23 revealed an original admission date on 04/05/22 and a readmission date of 10/15/22. Medical diagnoses included cerebral infarction, pain, fracture of rib, and difficulty in walking. Review of care plan dated 04/06/22 revealed Resident #23 was at risk for falls and had actual falls related to balance issues and weakness, macular degeneration, impaired cognition, impaired safety awareness, and repeated falls. Interventions included review information from past falls and attempt to determine the cause of falls, record possible root causes, alter or remove any potential causes if possible, and monitor/document/report as needed for 72 hours to physician for signs and symptoms of pain or injury and change in mental status. Resident #23 has potential acute and chronic pain related to history of frequent falls. Interventions included administer analgesic medications as per orders, monitor and report to nurse any signs and symptoms of non-verbal pain, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #23 required limited to extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #23 had one fall with injury, except major injury, since admission or the prior assessment. Review of physician orders for May 2022 revealed Resident #23 had an order for Acetaminophen 650 milligrams (mg) with orders to give one tablet every six hours as needed for mild pain. The order was entered with a start date of 04/14/22 and was discontinued on 05/25/22 at 10:28 A.M. Assess for pain every shift with a start date on 04/06/22. Review of the Morse Fall Scale assessment dated [DATE] at 12:50 A.M. revealed Resident #23 was a high risk for falling with a score of 80. Resident #23 had a history of falling. Resident #23 used an ambulatory aid and had a weak gait. Resident #23 overestimated or forgot limits. Review of the Incident Report dated 05/21/22 at 12:50 A.M. revealed the aide alerted Former Nurse (FN) #210 (no longer employed at facility) to Resident #23's fall. Resident #23 stated she was trying to find a snack. FN #210 observed Resident #23 sitting on the floor beside the bed with back facing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 11 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0697 Level of Harm - Actual harm Residents Affected - Few her night stand and leaning against the trash can. Resident #23 was wearing non-skid socks and walker was in front of her. Resident #23 was assisted off the floor with assistance from three staff and helped back into bed. Injury to the right rear iliac crest was noted with a pain level of five out of ten on the pain scale with ten being the worst pain level. Redness to Resident #23's right lower back was also noted. Resident #23 was noted to be ambulating without assistance. The fall was reviewed by the Interdisciplinary Team (IDT) and Resident #23 would be offered a snack and keep snacks at her bedside. Review of the Interdisciplinary Fall/Incident Investigation dated 05/28/22 revealed the date of the fall was 05/21/22 at 12:50 A.M. Resident #23 was found on the floor. The resident had a dry brief on. Resident #23 was alert to self, place, and situation. Resident #23 had complaint of pain to her iliac crest but was able to stand with assistance and transfer back to bed. The CNP was notified and x-rays were ordered that were returned with negative results. Resident #23 was administered Tylenol with mixed effectiveness 24 to 48 hours post fall. The CNP was notified of continued pain and was sent to the emergency room for pain medication. Review of progress notes dated from 05/21/22 through 05/31/22 revealed on 05/21/22 at 1:15 A.M., a progress note titled, Communication with Physician, that stated, alerted on call of resident fall and complaints of right lower back pain. Redness to area and rates pain five out of ten on the pain scale. Recommendations were a new order for a sacral and lower thoracic x-ray and to only call if fracture or abnormal findings were noted from x-ray. On 05/21/22 at 1:56 A.M., a progress note stated the aide alerted the nurse that Resident #23 was on the floor. The nurse entered the room and observed resident sitting on the floor on her bottom beside the bed with her back facing the night stand and leaned against trash can. Vital signs were within normal limits. Resident #23 complained of pain to her right lower back. Area was noted to be red on right lower back. The nurse asked Resident #23 if she would like to go to the hospital and the resident declined. Resident #23 stated she had pain when she moved. Tylenol was administered. The on-call physician/Certified Nurse Practitioner (CNP) was notified and a new order for an x-ray of sacral area and lower thoracic area was given. Assistant Director of Nursing (ADON) was notified. Resident #23 was educated to use call light for assistance. Will continue to monitor Resident #23. On 05/21/22 at 12:10 P.M., a progress note stated the nurse left a message for the CNP and requested a return call regarding Resident #23's as needed pain medication. Awaiting a return call. On 05/21/22 at 4:39 P.M., a progress note stated post fall day one, Resident #23 had pain to her right lower back and hip area. As needed (PRN) Tylenol was administered. No new skin issues were noted from fall. Awaiting results from the x-ray. On 05/21/22 at 5:18 P.M., a progress note stated xray results were received on this date and no acute fractures to the sacrum or spine were noted. On 05/21/22 at 11:36 P.M., a progress note stated post fall day one, no new skin issues were noted related to the fall. Resident #23 continued to complain of generalized pain. PRN Tylenol was administered with intermittent relief. On 05/22/22 at 11:21 P.M., a progress note stated Resident #23 complained of increased lower back pain. Resident #23 was administered PRN Tylenol with no relief. On-call provider was notified and an order was received to send Resident #23 to the emergency room for pain management. Resident #23 left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 12 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0697 the faciity on [DATE] at 11:20 P.M. (nearly two days following the fall). Level of Harm - Actual harm Review of the Order Administration Notes dated from 05/21/22 through 05/23/22 revealed on 05/21/22 at 12:56 A.M., an administration note stated Acetaminophen Tablet give 650 mg by mouth every six hours as needed (PRN) for mild pain. Complains of back pain. Residents Affected - Few On 05/21/22 at 10:00 A.M., an administration note stated Acetaminophen 650 mg by mouth every six hours as need for mild pain. Follow-up pain scale was four out of ten on the pain scale with 10 being the worst pain level. PRN administration was ineffective. On 05/22/22 at 7:00 P.M., an administration note stated Acetaminophen 650 mg by mouth every six hours PRN for mild pain. Resident #23 complained of lower back pain. On 05/22/22 at 10:07 P.M., an administration note stated Acetaminophen 650 mg by mouth every six hours as needed for mild pain. PRN administration was ineffective. Resident #23 continued to have increased pain. Follow-up pain scale was eight out of ten on the pain scale with ten being the worst pain level. Review of the Pain Tool assessment dated [DATE] at 12:50 A.M. revealed Resident #23 had pain on right iliac crest (rear) (located on right side of lower back above buttock). The pain was described as redness, sharp stabbing pain at first. Resident #23 stated she had pain with movement. Current pain level was noted as five out of ten on the pain scale with ten being the worst pain level and was marked as hurts even more on the faces scale. Rest made the pain better. Pain level at its least was described as three out of ten on the pain scale with ten being the worst pain level. Movement made the pain worse. Methods for alleviating pain were rest and PRN Tylenol. The effectiveness was not noted in the assessment. There were no additional Pain Tool assessments completed following Resident #23's fall. Review of the Medication Administration Record (MAR) dated May 2022 revealed Resident #23's pain levels 05/21/22 were six out of ten on the pain scale with ten being the worst pain during day shift and three during night shift. Pain levels on 05/22/22 were five out of ten on the pain scale with ten being the worst pain level during the day and eight during night shift. Acetaminophen Tablet give 650 mg by mouth every six hours as needed for mild pain was administered on 05/21/22 at 12:56 A.M. for a pain level of five out of ten on the pain scale with ten being the worst pain level. The medication was documented to be effective. On 05/21/22 at 7:34 A.M., the medication was administered for a pain level of six and was documented as ineffective. On 05/22/22 at 7:00 P.M. (approximately 36 hours later), the medication was administered for a pain level of eight out of ten on the pain scale with ten being the worst pain level and it was documented as ineffective. There were not any additional medications for pain administered to Resident #23. Review of hospital records dated 05/22/22 for Resident #23 revealed the resident admitted to the hospital on [DATE] at 11:40 P.M. with an expected discharge date of 05/25/22 (two days later). Resident #23's pain level on 05/22/22 at 11:50 P.M. was eight out of ten on a pain scale from zero to ten with ten being the worst pain level. The Attending Physician (AP) Note showed Resident #23 was seen, examined, and discussed with a trauma team. Findings included rib fracture. The traumatic event was noted as a ground level fall with complaint of back and rib pain following a fall two days prior at Resident #23's skilled nursing facility. Resident #23 had been complaining of some right posterior chest wall and back pain over the course of the last two days. Upon arrival, Resident #23 was evaluated with a comprehensive work-up which resulted in discovery of two isolated nondisplaced rib (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 13 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0697 Level of Harm - Actual harm Residents Affected - Few fractures at the right posterior chest wall, #8 and #9 respectively. Resident #23 complained of isolated right posterior chest wall pain and feeling fatigued due to inability to sleep over the last two days. Imaging results noted acute right posterior eighth and ninth rib fractures with additional healing right rib fractures. Resident #23 was noted to be awake and in mild painful distress. Oxycodone immediate release tablet 5 mg every eight hours as needed was ordered for pain. Interview on 03/16/23 at 2:06 P.M. with the Director of Nursing (DON) confirmed Resident #23 was not administered any additional pain medication other than PRN Tylenol from 05/21/22 around 1:00 A.M. through 05/22/22 around 11:30 P.M. (approximately two days) until the resident was sent out to the emergency room for pain management. The DON confirmed the PRN Tylenol medication was marked as ineffective and Resident #23 continued to complain of back pain. The DON confirmed there was also no evidence of any additional non-pharmacological interventions being attempted to reduce Resident #23's pain level. Review of the facility policy, Pain-Clinical Protocol, revised 03/2018, revealed the policy stated, with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 14 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy and procedure review, revealed the facility failed to ensure monthly pharmacy reviews are completed. This affected six residents (#16, #25, #28, #30, #42, and #258) of 11 residents reviewed for unnecessary medications. The census was 59. Findings include: 1. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual minimum data set (MDS) dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. There was no evidence of monthly pharmacy review for January 2023. 2. Review of Resident #28's medical record review revealed he was admitted to the facility on [DATE]. Diagnoses included psychosis, post traumatic stress disorder (PTSD), major depression, anxiety, anorexia, and peripheral vascular disease. Review of the significant change MDS assessment dated [DATE] revealed his cognition was not intact. He required total dependence of two or more staff members physical assistance for bed mobility, transfers, and toilet use. He required extensive assistance of one staff member physical assistance for personal hygiene and dressing. There was no evidence of monthly pharmacy review for January 2023. 3. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression, diabetes, and congestive heart failure (CHF). Review of the quarterly MDS assessment dated [DATE] revealed his cognition was mildly impaired. He required extensive assistance of two plus staff members physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Received antipsychotic, antianxiety and antidepressants. There was no evidence of monthly pharmacy review for January 2023. Interview with the Director of Nursing (DON) on 03/16/23 at 10:47 A.M. confirmed she still has not received monthly medication review lists for January and February 2023. The DON states she has reached out to the consulting pharmacy to obtain the needed information. Also, the DON confirmed she had not received the actual pharmacy recommendations that were made on those months to ensure the physician/CNP addressed the recommendations. Again, the DON indicated she had requested the information from the pharmacy but has not received it yet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 15 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility policy Medication Regimen Review dated 04/18 revealed the consultant pharmacist performs a comprehensive review of each residents medication regimen and clinical record at least monthly. 4. Review of Resident #25's medical record revealed an original admission date on 06/24/22 and a readmission date on 12/31/22. Diagnoses included Type II Diabetes Mellitus with foot ulcer, liver disease, anxiety disorder, and depression. Review of the Medicare 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #25 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). There were not any behaviors noted in the assessment. Resident #25 had signs of mild to moderate depression and scored eight out of 27 on the Mood Interview or PHQ-9. Resident #25 was noted to receive daily insulin injections, antianxiety, antidepressant, and opioid medications. Review of the care plan dated 11/08/22 revealed Resident #25 used antianxiety medications related anxiety disorder. Interventions included administer medications as ordered by physician and monitor for side effects and effectiveness every shift and monitor/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate responses to verbal communication, violence/aggression towards staff or others and document per facility protocol. Resident #25 used antidepressant medication related to depression. Interventions included administer antidepressant medications as ordered by physician and monitor/document side effects and effectiveness and monitor/document/report as needed changes in behavior/mood/cognition including: social isolation, suicidal thoughts, withdrawal, decline in ADL ability, fatigue, insomnia, or weight loss. Review of monthly medication regimen reviews dated from 05/01/22 through 02/28/23 revealed there was not any evidence Resident #25's medications were reviewed in January 2023 or February 2023. There was not any evidence of any pharmacy recommendations made for Resident #25 in January 2023 or February 2023. Interview on 03/16/23 at 10:47 A.M. with the Director of Nursing (DON) confirmed she still had not received monthly medication review lists for January 2023 or February 2023. The DON stated she had reached out to the consulting pharmacy to obtain the needed information but had not received anything yet. Also, the DON confirmed she had not received the actual Gradual Dose Reductions (GDRs) and/or pharmacy recommendations that were made in January 2023 or February 2023 to ensure the physician or Certified Nurse Practitioner (CNP) addressed the recommendations in a timely manner. The DON had requested this information as well but had not received it yet. 5. Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #30 received daily insulin injections, antianxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 16 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0756 antidepressant, anticoagulant, and diuretic medications. Level of Harm - Minimal harm or potential for actual harm Review of monthly pharmacy reviews revealed there was not any evidence of a monthly pharmacy review for 02/2023. Residents Affected - Some Interview on 03/16/23 at 10:47 A.M. with the Director of Nursing (DON) confirmed she still had not received monthly medication review lists for February 2023. The DON stated she had reached out to the consulting pharmacy to obtain the needed information but had not received anything yet. Also, the DON confirmed she had not received the actual Gradual Dose Reductions (GDRs) and/or pharmacy recommendations that were made in February 2023 to ensure the physician or Certified Nurse Practitioner (CNP) addressed the recommendations in a timely manner. The DON had requested this information as well but had not received it yet. Review of the facility policy, Medication Regimen Review, dated 04/2018, revealed the policy stated, the consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator. 6. Review of the medical record for Resident #258 revealed an admission date of 12/02/22 with diagnosis of Alzheimer's Disease; dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; paroxysmal atrial fibrillation; atrial flutter; pulmonary embolism with acute cor pulmonale; metabolic encephalopathy; and malignant neoplasm of the body of the pancreas. Review of the physician's orders for Resident #258 identified an order for Seroquel 50 milligrams by mouth one time a day for mood. There was a pharmacy recommendation dated 01/17/23 but there was no pharmacy recommendation for February 2023. Interview with Director Of Nursing (DON) on 03/16/23 at 10:47 A.M. confirmed the missing pharmacy recommendation for Resident #258. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 17 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on open and closed medical record reviews, interviews with staff, review of side effects for Paxlovid (an antiviral medication), review of interaction warning for Paxlovid medication, review of fact sheet on Paxlovid, review of hospital records, and facility policy review, the facility failed to adequately monitor residents for signs and symptoms of bleeding while taking an anticoagulant medication. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #56 was prescribed Paxlovid (an antiviral medication) twice daily for five days to treat COVID-19 infection while also taking Rivaroxaban (generic brand for Xarelto), an anticoagulant medication. The facility failed to monitor Resident #56 for signs of bleeding and the resident subsequently exhibited signs of internal bleeding on [DATE] without facility intervention including notification of the medical practitioner. The Immediate Jeopardy continued [DATE] when Resident #56 again had signs of internal bleeding and was noted to have a moderate amount of blood in her stool and complained of abdominal pain. Resident #56 became lethargic, pale, and difficult to arouse, was sent to the emergency room for evaluation and treatment where she passed away from a brain bleed and a gastrointestinal (GI) bleed. Residents Affected - Few In addition, concerns that did not rise to the level of Immediate Jeopardy were identified when six additional residents (Resident #9, #15, #30, #42, #48, and #109) reviewed for anticoagulant medication administration were identified without a care plan and/or adequate monitoring for signs and symptoms of side effects (including bleeding) from the anticoagulant medications. This affected seven residents (Resident #9, #15, #30, #42, #48, #56, and #109) of eight residents reviewed for anticoagulant medications. The facility census was 59. On [DATE] at 3:41 P.M. the Director of Nursing (DON) and Unit Manager (UM) #101 were notified Immediate Jeopardy began on [DATE] when Resident #56 was prescribed Paxlovid (a medication to treat COVID-19) while concurrently being administered the anticoagulant medication, Xarelto without any increased monitoring for any signs and symptoms of bleeding or bruising despite the warning that the two medications could have a severe interaction causing increased bleeding. On [DATE], Resident #56 was noted to have reddish colored urine but staff failed to notify Certified Nurse Practitioner (CNP) #192 of the change in condition and failed to complete any additional monitoring for signs and symptoms of bleeding or bruising. On [DATE] at 2:19 P.M., Resident #56 was noted to have a moderate amount of blood in her stool and complained of abdominal pain. On [DATE] at 3:24 P.M., Resident #56 was lethargic, pale, and difficult to arouse. The resident was sent to the emergency room. On [DATE] at 9:43 P.M., the facility was notified by Resident #56's family the resident had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] by 3:00 P.M. care plans for each resident who was receiving anticoagulant therapy were reviewed and updated to address anticoagulant therapy by Minimum Data Set (MDS) Nurse #128 with documentation on the care plan. This includes all potentially affected residents, Resident #8, #15, #258, #109, #30, #3, #50, #42, #37, #12, #9, #29, #6, #48, #44, #5, #41, #13, and #20. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 18 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] by 3:00 P.M. each nurse (nine registered nurses and 12 licensed practical nurses) and 30 Nursing Assistantswere educated in person or telephonically regarding monitoring for adverse effects of anticoagulant therapy by DON, Unit Manager #149, Unit Manager #l01. • On [DATE] at 4:30 P.M. a discussion with Pharmacy Manager #220, Facility Pharmacist #221, Pharmacist #190, and Pharmacist #195 regarding drug interactions, process for contacting facility based on the level of severity of the interaction (mild/moderate/severe) and agreement was made for the pharmacy to call the facility for all severe interactions was held. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. Pharmacist will not dispense medication and contact facility by phone. If there is a potential interaction, the pharmacy will not dispense medication until receiving verification from physician. The consulting pharmacist also completes a monthly review, the consulting pharmacist reviews the patient's current active medications every month and provides recommendations for nursing and medical staff follow-up. • On [DATE] by 5:00 P.M. all residents receiving anticoagulant therapy including Residents #15, #8, #258, #109, #30, #3, #50, #42, # 37, # 12, # 9, #29, #6, #48, #44, #5, #41, #13 and #20 had skin assessments completed by nurse weekly. The skin assessment monitors for any new areas on the skin including signs of adverse effects of anticoagulant. These residents were assessed by the nurse with no adverse effects found. • On [DATE] at 6:00 P.M. information was provided to the facility Quality Assessment and Performance Improvement (QAPI) Committee for review and additional guidance. The Medical Director provided input and approved the facility's abatement plan on 03/l 7/23 at 6:00 P.M. • On [DATE] by 7:00 P.M. each nurse was educated in person or telephonically regarding the process for handing potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. Drug interactions will be assessed by the pharmacy. Their dispensing system will flag drug interactions as they verify the order and physician will be notified of potential interaction by facility. If the drug is flagged for an interaction, the pharmacy will not dispense medication until receiving verification from physician. • On [DATE] by 8:00 P.M. a whole house audit for residents receiving anticoagulants was completed by the Director of Nursing (DON) or designee. No residents were noted to have adverse side effects from anticoagulants. Orders were verified to be in place and updated to monitor for adverse effects of anticoagulant therapy and if noted to report to the physician as clinically indicated for all residents who have orders for it. This was completed on [DATE] at 2:36 P.M. by Nurse Unit Manager #101. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 19 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] by 8:00 P.M. all 30 State Tested Nursing Assistants (STNAs) were educated to report any signs of bleeding or bruising to the nurse and to ensure that the nurse visualized the concern by the DON, Unit Manager #149, or Unit Manager #101. • On [DATE] by 8:00 P.M. the DON, Unit Manager #149, or Unit Manager # 101 completed an audit on all residents receiving anticoagulation therapy to include physician orders and care plans for monitoring adverse effects i.e.: bruising and bleeding. Residents #8, #15, #42, #258, #109, #30, #3, #37, #12, #9, #44, #5, and# 41 had care plans with anticoagulant monitoring. These care plans were reviewed and updated as necessary with documentation of the additions. The audit showed that Residents #50, #29, # 6, #48, #13, and #20 did not have care plans that addressed monitoring for adverse effects of anticoagulants. Appropriate interventions were added by the MDS Nurse #128 by 6:00 P.M. on [DATE]. • On [DATE] by 8:00 P.M. the DON developed a monitoring tool and implemented monitoring tool and process of adverse effects of anticoagulant medications. This was implemented on [DATE] by 12:00 P.M. Monitoring tool will include list of residents on anticoagulant therapy and verification that monitoring was completed as ordered. This monitoring will be completed by DON, Unit Manager #149, or Unit Manager #101 that was trained on [DATE] by 8:00 P.M. • On [DATE] by 12:00 P.M. the facility implemented a plan for audits to be conducted twice a week for two weeks and then weekly for a month by the DON, Unit Manager #149, or Unit Manager #101 to check for orders and care plans for monitoring of adverse effects of anticoagulant medications for all resident who have received them. • On [DATE] at 12:00 P.M. the facility implemented a plan for audits on drug interactions and ensuring appropriate follow-up were completed and will be reviewed weekly by the QAPI Committee for two weeks. QAPI team will provide further guidance and monitoring as needed. • On [DATE] at 3:00 P.M. the DON implemented an audit tool to monitor for appropriate follow up on each drug interaction and MMR made by the pharmacy. Audits will be conducted twice a week for 2 weeks and then weekly for a month by DON or designee. • On [DATE] at 5:00 P.M. each nurse (12 LPNs and 9 RNs) were educated in person or via telephone regarding the process for handling potential drug interactions by the DON, Unit Manager #149, or Unit Manager #101. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 20 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE] at 9:18 A.M. interviews with RN #152, STNA #160 and STNA #167 revealed all staff interviewed had received facility education related to anticoagulant medication use, drug interactions and/or monitoring for signs/symptoms of bleeding/bruising. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: 1.Review of the closed medical record for Resident #56 revealed an admission date on [DATE] and a discharge date due to death on [DATE]. Medical diagnoses included major depressive disorder, anxiety disorder, gastrostomy status, tracheostomy status, unspecified psychosis, hypertension (HTN), malignant neoplasm of unspecified female breast, unspecified open wound of unspecified part of head, unspecified fractures of lower left femur, neck, multiple ribs on left side, and shaft of left clavicle, and displaced fracture of sixth cervical vertebra. Review of a hospital discharge record dated [DATE] (prior to admission to the facility) revealed Resident #56 sustained multiple fractures from a motor vehicle accident. Resident #56 was prescribed the anticoagulant medication, Xarelto for a diagnosis of coagulopathy (a condition in which the blood's ability to form clots is impaired). Resident #56 received surgical intervention to repair injuries to her left leg. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of three out of 15. The assessment revealed Resident #56 required extensive assistance to total dependence from one to two staff to complete activities of daily living (ADLs). The assessment did not indicate Resident #56 had received an anticoagulant medication daily. The assessment was incorrect as the resident had received an anticoagulant daily. Review of the physician's orders revealed Resident #56 had a medication order, dated [DATE] for Rivaroxaban (generic for Xarelto) 20 milligrams (mg) via peg tube one time daily for prevention. The medication was ordered by Physician #200. On [DATE] the resident had an order for Paxlovid (300/100) oral tablet therapy pack twenty X 150 milligrams (mg) and ten X 100 mg with instructions to give 300 mg via peg-tube two times daily for COVID-19 for five days and give 100 mg via peg tube two times a day for COVID-19 for five days. The medication was ordered by Certified Nurse Practitioner (CNP) #192. There was not a physician order to monitor for side effects or signs and symptoms of bleeding in place. Review of the Paxlovid order, dated [DATE] at 3:59 P.M. revealed the medication had an ALERT! Drug Interaction. The alert was located on the right-hand side in the electronic medical record when the physician order was clicked on to be viewed. Review of the Drug-to-Drug Interaction Details, viewed when the medication alert was clicked on in the electronic medical record, revealed there was a severe interaction with Rivaroxaban (Xarelto) medication which stated, Coadministration of rivaroxaban with combined Paxlovid should be avoided according to official package labeling in the United States. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 21 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Review of an electronic Medication Administration Record (eMAR) note, titled Orders-Administration Note in the progress notes section of the electronic medical record, dated [DATE] at 4:01 P.M. revealed the system had identified a possible drug interaction with a severity of severe with Rivaroxaban with plasma concentrations and pharmacologic effects of Rivaroxaban may be increased in combination with Paxlovid. Coadministration of Rivaroxaban with Paxlovid should be avoided according to official package labeling in the United States. Residents Affected - Few Review of the resident's care plan revealed the plan of care did not address anticoagulant medication or monitoring for signs and symptoms of bleeding or bruising. Review of a progress note from Certified Nurse Practitioner (CNP) #192 dated [DATE] revealed Resident #56 was seen for follow up due to COVID-19 diagnosis. Resident #56's medications were reviewed and reconciled. Care included to start COVID-19 protocol, Paxlovid 150/100 therapy pack twice daily for five days due to Resident #56's COVID-19 positive diagnosis. There was no mention of a possible interaction with Xarelto medication. Review of a progress note from CNP #203 dated [DATE] revealed Resident #56 was seen for follow up related to COVID-19 diagnosis. The resident's medications were reviewed and reconciled, and the resident would continue medications, including Paxlovid 300 mg twice daily. There was no mention of a possible interaction with Xarelto medication. Review of the Medication Administration Record (MAR) dated [DATE] revealed Resident #56 received Rivaroxaban daily as ordered and Paxlovid twice a day for five days (a total of ten doses) from [DATE] to [DATE] as ordered. Review of progress notes dated from [DATE] through [DATE] revealed on [DATE] at 6:40 A.M., an unidentified State Tested Nursing Assistant (STNA) reported to Licensed Practical Nurse (LPN) #107 that Resident #56's urine color appeared reddish. Resident #56's vital signs were within normal limits and the resident denied any pain. The morning shift nurse (unidentified) was notified. There was no evidence the CNP or physician were notified of the change in condition. On [DATE] at 2:19 P.M., a progress note entered by Registered Nurse (RN) #152 revealed an unidentified STNA called the nurse to Resident #56's room. The resident had a moderate amount of blood in stool and Resident #56 complained of pain to abdomen. The resident's blood pressure was 112/60. CNP #205 was notified and new orders for an abdominal x-ray, complete blood count (CBC), and complete metabolic panel (CMP) were provided. On [DATE] at 3:24 P.M. (approximately one hour later), a progress note entered by RN #152 revealed Resident #56 was lethargic, pale, and difficult to arouse. Resident #56's temperature was 100.3 degrees Fahrenheit and blood pressure was 141/97. CNP #205 was notified and a new order to send Resident #56 to the emergency room was given. On [DATE] at 9:43 P.M., a progress note entered by RN #156 revealed Resident #56's family called to notify the facility that Resident #56 had passed away as a result of a brain bleed and a gastrointestinal (GI) bleed. Review of hospital records, dated [DATE] at 4:02 P.M. revealed Resident #56 had a history of deep vein thrombosis and was on Xarelto medication. The resident presented to the hospital for an evaluation of unresponsiveness. The records noted staff checked on Resident #56 at 1:00 P.M. and she had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 22 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few complained of abdominal pain and when checked again at 3:30 P.M., the resident was unresponsive. At 5:20 P.M., the radiologist reported Resident #56 had a large intraparenchymal hemorrhage of the right frontal lobe with mass-effect and vasogenic edema (a brain bleed). KCentra (a medication to reverse effects of anticoagulant) and Vitamin K were ordered. The family reported Resident #56 had dark stools and there was concern for GI bleeding. A rectal exam was performed and was positive for bloody stool. Troponin levels were elevated likely due to blood loss and hemoglobin was 7.1. Resident #56 was admitted to the Intensive Care Unit (ICU) for further critical care treatment. Resident #56 was pronounced deceased on [DATE] at 9:30 P.M. at the hospital. Interview on [DATE] at 2:51 P.M. with the Director of Nursing (DON) revealed Resident #56 was fine and was not on the radar for any concerns except weight gain prior to [DATE]. The DON stated she was notified on [DATE] of Resident #56's bloody stool. The DON was not aware and had not been notified of reddish colored urine on [DATE]. The DON confirmed Resident #56 was on an anticoagulant medication, Xarelto, and reddish colored urine would be a potential sign of bleeding. The DON stated she would have expected the CNP to be notified by the staff, additional monitoring for any other possible signs or side effects, a urine sample to be obtained and sent out for testing, and possibly additional lab work to be ordered. Interview on [DATE] at 3:57 P.M. with CNP #192 revealed she had not been notified that Resident #56 had reddish colored urine on [DATE]. CNP #192 stated she was not aware of any signs or symptoms of bleeding prior to [DATE]. CNP #192 confirmed Resident #56 was on Xarelto, an anticoagulant. CNP #192 stated staff noted resident concerns in a binder that she reviewed when she was on-site at the facility. CNP #192 confirmed the binder did not note any reddish colored urine for Resident #56. CNP #192 stated had she been notified of the change, she would have requested a more detailed description of the urine, ordered labs, and would have wanted the staff to continue monitoring for any signs or symptoms of bleeding (including blood in urine, blood in stool, or any increased bruising). Interview on [DATE] at 4:36 P.M. with CNP #192 revealed drug interactions between medications occur constantly and she would only consider stopping an anticoagulant if the interaction was a severe interaction. CNP #192 stated she assessed the benefits versus the risks of continued administration of Paxlovid and Xarelto together and felt the benefits outweighed the risks at that time to treat COVID-19 infection. CNP #192 confirmed she was aware of the possible severe interaction between the two medications and confirmed administering Paxlovid with Xarelto may increase bleeding. CNP #192 confirmed she should have been notified of Resident #56's reddish colored urine on [DATE] and would have expected staff to be monitoring Resident #56 of any signs or symptoms of bleeding while on the anticoagulant medication. Interview via telephone on [DATE] at 9:53 A. M. with Pharmacist #190 revealed she was a new consulting pharmacist who conducted monthly medication reviews at the facility since [DATE]. Pharmacist #190 stated a national software was used to identify drug interactions. If a severe interaction was identified, Pharmacist #190 notified the physician/DON/nurse manager directly due to the need for immediate attention as well as write a pharmacy recommendation. The pharmacist revealed it was the prescriber of the medication who made the final decision whether to continue administering the medications. Pharmacist #190 stated Paxlovid was a new medication and interacted with several medications. Pharmacist #190 confirmed Paxlovid administered with Xarelto could increase bleeding. Interview via telephone on [DATE] at 11:06 A.M. with Pharmacist #195 revealed he was a pharmacist with Complete Pharmacy Solutions, the pharmacy used to fill the facility's medication prescriptions. Pharmacist #195 stated medication orders were received via fax, electronically, or verbally but the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 23 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few bulk of the facility's orders were received by fax. Pharmacist #195 confirmed he checked for medication interactions with new prescriptions to ensure it was clinically safe to administer the medications prior to filling the prescription. If a severe interaction was identified, Pharmacist #195 stated he contacted the floor nurse who cared for the resident of the possible interaction. Pharmacist #195 confirmed there was risk for increased bleeding when Paxlovid and Xarelto were administered together. Pharmacist #195 stated a risk assessment would be completed with the floor nurse to review the benefits versus the risks of continuing administration of the medications together. Pharmacist #195 confirmed Paxlovid and Xarelto administered together would be a more major drug interaction with an increased risk of increased bleeding. Pharmacist #195 stated the resident should be monitored for signs and symptoms of increased bleeding. Pharmacist #195 confirmed Paxlovid was dispensed to the facility on [DATE] and confirmed Resident #56 was also on Xarelto for a long time. Pharmacist #195 stated the order was called in to the pharmacy by Nurse #207 and the same nurse would have been notified of the possible severe drug interaction. Interview via telephone on [DATE] at 4:50 P.M. with Physician #200 revealed he was aware Resident #56 was taking Paxlovid and Xarelto together to treat COVID-19 infection. Physician #200 revealed he felt the benefits outweighed the risks of administering the medications together at the time. However, Physician #200 confirmed the facility staff absolutely should have notified himself and/or the CNP of any signs or symptoms of bleeding for Resident #56. Physician #200 confirmed he was not notified of Resident #56's reddish colored urine on [DATE]. Physician #200 stated had he been notified of the reddish colored urine on [DATE], increased monitoring would have been initiated in an attempt to identify the cause of the reddish colored urine. Review of Paxlovid: What Prescribers and Pharmacists Need to Know, dated [DATE], revealed, there is uncertainty about effect magnitude in target populations and high certainty for harm with Paxlovid if drug interactions are not mitigated. Additionally, the fact sheet showed the recommendation if a resident was on Rivaroxaban (Xarelto) was do not coadminister, hold and restart two days after completing Paxlovid, and significant questions in drug concentrations expected. Do not coadminister due to risk of serious toxicity. If possible, use alternative COVID-19 agent. If not possible, then: low risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND aspirin 81 mg daily. Finish Aspirin one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. High Risk of clot: hold rivaroxaban. 24 hours after the last dose of rivaroxaban, start Paxlovid AND therapeutic dosing of a subcutaneous low molecular weight heparin (LMWH). Finish LMWH one day after completing Paxlovid. Restart Rivaroxaban two days after completing Paxlovid. Review of Paxlovid Side Effects Center, dated [DATE], revealed Paxlovid had an established significant drug interaction with Rivaroxaban. Clinical comments included, Increased bleeding risk with Rivaroxaban. Avoid concomitant use. Review of the facility policy titled, Anticoagulation-Clinical Protocol, revised 11/2018, revealed the policy stated, as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medications should be assessed for bleeding.) The physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines. The physician will collaborate with the consultant pharmacist and nursing staff to identify potentially serious medication interactions with anticoagulants. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 24 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety physician should adjust the anticoagulant dose or stop, taper, or change medications that interact with the anticoagulant. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. Review of the undated facility policy, Medications and Treatment Orders, revealed: Residents Affected - Few • If a medication triggers with a severe interaction when putting it in resident's orders, physician will be notified, and pharmacy will verify medication· with the provider. This will also be documented in resident's chart. • When there is a medication which triggers with severe interactions and physician or NP chooses to continue with this medication therapy rational will be documented in a resident's record. • Medications which have the potential for adverse reactions or side effects including anticoagulants, antibiotics etc . will have increased monitoring to meet assessment heeds. If any adverse reactions or side effects are noted, physician or NP will be notified immediately. 2. Review of Resident #9's medical record revealed an initial admission date of [DATE] and readmission date on [DATE]. Medical diagnoses included dementia with other behavioral disturbance, unspecified atrial fibrillation, presence of cardiac pacemaker, chronic kidney disease Stage 3, and metabolic encephalopathy. Review of the care plan dated [DATE] revealed Resident #9's care plan addressed the resident taking an anticoagulant medication with interventions to monitor for signs and symptoms of bleeding. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required supervision from staff to complete Activities of Daily Living (ADLs). Resident #9 was administered anticoagulant medication daily. Review of the physician's orders for [DATE] revealed Resident #9 had an order for Eliquis (an anticoagulant medication) 5 milligrams (mg) with instructions to give one tablet by mouth twice daily for atrial fibrillation. The order had a start date of [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 25 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few There were not any orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (after surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #9 received Eliquis medication twice daily as ordered unless the resident refused the medication. There was no evidence of any monitoring for side effects or bleeding noted on the MAR or the TAR for any of the three months. Review of progress notes dated from [DATE] through [DATE] revealed there was no evidence Resident #9 was monitored for any signs or symptoms of bleeding or side effects of anticoagulant medication. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #9 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. 3. Review of Resident #30's medical record revealed an original admission date on [DATE] and a readmission date on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of the plan of care dated [DATE] revealed Resident #30 had a history of deep vein thrombosis (blood clots). Interventions included to monitor/document/report as needed any signs or symptoms of blood clots including abnormal bleeding, bruising, or petechiae (related to anticoagulant use). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #30 received daily anticoagulant medication. Review of physician's orders dated [DATE] revealed Resident #30 had an order for Eliquis (an anticoagulant medication) 2.5 milligrams (mg) with instructions to give one tablet twice daily for deep vein thrombosis (blood clot) prophylaxis. This order was dated [DATE] and the medication started [DATE]. There were no additional orders to monitor for side effects or signs and symptoms of bleeding until [DATE] when an order was added (following surveyor intervention). Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated [DATE], February 2023, and [DATE] revealed Resident #30 received anticoagulant medication twice daily as ordered. There was no evidence in the MARs or TARs Resident #30 was monitored for any side effects or signs and symptoms of bleeding while taking the anticoagulant medication. Review of the progress notes dated from [DATE] to [DATE] revealed there was not any evidence Resident #30 was monitored for side effects or signs and symptoms of bleeding. Interview on [DATE] at 3:49 P.M. with the Director of Nursing (DON) confirmed there was no evidence Resident #30 was being monitored for side effects or signs and symptoms of bleeding while being administered an anticoagulant medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 26 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0757 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the facility policy, Anticoagulation-Clinical Protocol, revised 11/2018, revealed the policy stated, the physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications: for example, periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood. The staff and the physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs and symptoms or evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant as indicated. 4. Review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, pneumonia, acute myocardial infarction, hemiplegia, metabolic encephalopathy, diabetes, acute kidney failure and heart failure. Review of Resident #15's physician orders dated [DATE] revealed an order for L[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 27 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual MDS dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Review of the Pharmacy recommendation for 02/25/23 revealed Resident #16 has been taking Latuda 40 mg daily for bipolar disorder since March 2022. Please evaluate the potential for a dose reduction at this time to determine the lowest, effective dose. If contraindicated please provide a brief note. 5. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, anxiety, schizophrenia, dementia, severe protein malnutrition, depression, diabetes, and congestive heart failure (CHF). Review of the quarterly minimum data set assessment dated [DATE] revealed his cognition was mildly impaired. He required extensive assistance of two plus staff members physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. Received antipsychotic, antianxiety and antidepressants. Review of Pharmacy recommendation for 02/25/23 revealed Resident #42 is currently receiving an antidepressant. CMS guidelines recommend trial reduction two times during the first year of therapy and then a trial reduction yearly thereafter. As of 03/17/23 there was no documented evidence the physician acted upon the pharmacy recommendation. On 03/16/23 at 10:47 A.M. interview with the DON confirmed she has not received the actual gradual dose reductions for Residents #16 and #42 and they have not been addressed by the physician. Based on medical record review, review of pharmacy recommendations, staff interview, and facility policy review, the facility failed to provide appropriate justification for the use of an antipsychotic medication for two residents (Residents #30 and #258), failed to ensure pharmacy recommendations were reviewed and addressed timely by the physician for two resident (Residents #16 and #42), failed to adequately monitor behaviors for one resident (Resident #25) on antianxiety and antidepressant medications, and failed to ensure an as needed (PRN) antipsychotic medication had an appropriate stop date for one resident (Resident #9). This affected six residents (Residents #9, #16, #25, #30, #42 and #258) out of 11 residents reviewed for unnecessary medications. The facility census was 59. Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date on 04/19/19 and a readmission date on 10/23/19. Medical diagnoses included dementia with other behavioral disturbance, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 28 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0758 insomnia, dizziness and giddiness, anxiety disorder, and metabolic encephalopathy. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders dated March 2023 revealed Resident #9 had the following order in place: Haloperidol (an antipsychotic medication) 1 milligram (mg) with instructions to give one tablet every six hours as needed (PRN) for aggression/agitation. The order was dated 02/12/23 and did not have a stop date on the order. Residents Affected - Some Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had impaired cognition and scored a six out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Behaviors noted included hallucinations, delusions, physical behavior towards others one to three days during the review period, and other behavior symptoms toward others on four to six days during the review period. Resident #9's behavior puts the resident at significant risk for physical illness or injury, significantly interferes with the resident's care, and significantly interferes with the resident's participation in activities or social interactions. Resident #9's behaviors were notes as worse than the previous assessment. Resident #9 required limited assistance to extensive assistance from one staff to complete Activities of Daily Living (ADLs). Resident #9 received an antipsychotic medication on two days with no gradual dose reduction attempted. Interview via email on 03/20/23 at 3:09 P.M. with the Director of Nursing (DON) confirmed Resident #9's order for PRN Haloperidol did not have an appropriate stop date for a PRN antipsychotic medication. Review of the facility policy, Medication Monitoring and Management, revised 01/2018, revealed the policy stated, for antipsychotics the continued use is in accordance with relevant current standard of practice and the physician documents the clinical rationale. 2. Review of the medical record for Resident #25 revealed an admission date on 06/24/22 and a readmission date on 12/31/22. Medical diagnoses included diabetes mellitus with foot ulcer, liver disease, anxiety disorder, and depression. Review of the physician orders dated March 2023 revealed Resident #25 had the following medication orders: Fluoxetine Hydrochloride (HCL) 10 milligrams (mg) with instructions to give one tablet by mouth daily for depression. The order was dated 12/31/22. Buspirone Hydrochloride (HCL) 15 mg with instructions to give one tablet by mouth twice daily for anxiety. The order was dated 12/31/22. There was not an order to monitor Resident #25's behaviors. Review of the Medicare 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. No behaviors were noted in the assessment. Resident #25 required extensive assistance with one to two staff to complete Activities of Daily Living (ADLs). Resident #25 received daily insulin injections, antianxiety, and antidepressant medications. Review of the care plan dated 11/08/22 revealed Resident #25 used antianxiety medications related anxiety disorder. Interventions included administer medications as ordered by physician and monitor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 29 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for side effects and effectiveness every shift and monitor/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate responses to verbal communication, violence/aggression towards staff or others and document per facility protocol. Resident #25 used antidepressant medication related to depression. Interventions included administer antidepressant medications as ordered by physician and monitor/document side effects and effectiveness and monitor/document/report as needed changes in behavior/mood/cognition including: social isolation, suicidal thoughts, withdrawal, decline in ADL ability, fatigue, insomnia, or weight loss. Review of the task for behavior monitoring for the previous 30 days revealed there was not any data entered in the resident's record related to behavior monitoring. Interview on 03/16/23 at 11:25 A.M. with the Director of Nursing (DON) confirmed there was not any evidence that Resident #25 displayed any behaviors to justify the use of antidepressant or antianxiety medication. The DON also confirmed there was not any evidence that Resident #25's behaviors were being monitored in the resident's record. 3. Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), orthostatic hypotension, end stage renal disease, paroxysmal atrial fibrillation, and Type II Diabetes Mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #30 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #30 received daily insulin injections, antianxiety, antidepressant, anticoagulant, and diuretic medications. Review of pharmacy recommendation dated 10/20/22 revealed Resident #30 had an order for Hydroxyzine 25 milligrams (mg) twice daily as needed (PRN) for anxiety. The pharmacist recommended: indicate duration and document rationale for the stated time frame or the medication can be changed to routine or discontinued. Physician #200 disagreed with the pharmacist recommendation with the rationale of leave order as is on 10/25/22. There was no additional reason provided for continuing the medication as ordered. Review of the physician orders dated March 2023 revealed Resident #30 had an order for Hydroxyzine Hydrochloride (HCL) 25 mg every 12 hours PRN for anxiety dated 09/21/22. Interview on 03/15/23 at 3:05 P.M. with the Director of Nursing (DON) confirmed the pharmacy recommendation to add a stop date or provide rationale for continuing PRN Hydroxyzine for Resident #30 did not have an acceptable rationale from the physician or a stop date added as recommended. 6. Review of the medical record for Resident #258 revealed an admission date of 12/02/22 with diagnoses of Alzheimer's Disease; dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; paroxysmal atrial fibrillation; atrial flutter; pulmonary embolism with acute cor pulmonale; metabolic encephalopathy; and malignant neoplasm of the body of the pancreas. Review of the physician's orders dated 02/22/23 for Resident #258 identified an order for Seroquel 50 milligrams by mouth one time a day for mood with no end date. The dementia diagnosis for Resident #258 states dementia without behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 30 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0758 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed no psychosis or behavioral symptoms noted during the look back period and Resident #258 was receiving an antipsychotic and antidepressant. There has been no gradual dose reduction and no physician documentation of a gradual dose reduction would be contraindicated. Residents Affected - Some The 12/21/22 Pharmacy recommendation for Resident #258 stated: The resident is receiving the antipsychotic quetiapine (Seroquel) 100 mg daily for a diagnosis of depressions. This diagnosis may not support the use of an antipsychotic. There needs to be evidence in the chart that one of the following conditions exists: The symptoms are identified as being due to mania or psychosis (i.e., auditory/visual/other hallucinations or delusions) The behavioral symptoms present a danger to the resident or others and non-med interventions have failed. Consider a dose decrease when appropriate. Review of the medical record revealed on 01/02/23 the document was signed, stated the physician disagreed with the dose reduction, the documentation only stated Resident #258 has agitation and anxiety with mood swings. The 01/17/23 Pharmacy recommendation for Resident #258 revealed: The resident is receiving the antipsychotic quetiapine (Seroquel) 100 mg daily for a diagnosis of depressions. This diagnosis may not support the use of an antipsychotic. There needs to be evidence in the chart that one of the following conditions exists: The symptoms are identified as being due to mania or psychosis (i.e., auditory/visual/other hallucinations or delusions) The behavioral symptoms present a danger to the resident or others and non-med interventions have failed. Consider a dose decrease when appropriate. Review of physician's orders dated 01/19/23 revealed an order for Seroquel 75 milligrams (25 milligram tablets give three tablets) once a day for depression to start 01/19/23 with no end date. Review of Resident #258's behaviors documented in the electronic medical record on 03/16/23 with a look back period of 14 days revealed no behaviors documented. There was no pharmacy review information for February 2023. On 03/16/23 at 10:47 A.M. interview with the DON confirmed the lack of behaviors documented for Resident #258 and the failure to adequately address the pharmacy recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 31 of 32 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 365794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pataskala Oaks Care Center 144 East Broad Street Pataskala, OH 43062 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on review of the staff vaccination matrix, staff interview, and facility policy review, the facility failed to ensure all staff were vaccinated against the COVID-19 virus or had a valid exemption on file prior to working in the facility. This had the potential to affect all 59 residents who resided in the facility. Residents Affected - Many Findings Include: Review of the Staff Vaccination Matrix dated 03/15/23 revealed Dietary #180 was listed as unvaccinated. The facility had a total of 84 staff and 83 staff were either vaccinated or had a religious exemption on file. Interview on 03/14/23 at 1:34 P.M. with the Director of Nursing (DON) revealed the facility had a total of 84 staff; 19 staff had religious exemptions on file. One staff, Dietary #180 was unvaccinated. Dietary #180 was contacted on 03/13/23 and should be attending a vaccine clinic on 03/16/23. Interviews on 03/15/23 at 3:48 P.M. and 5:30 P.M. with the DON confirmed Dietary #180's hire date was 02/15/23. Dietary #180's first day of work was 02/18/23. Dietary #180 had worked a total of 19 shifts since her hire date unvaccinated against COVID-19. Vaccination clinics were offered to Dietary #180 on 02/23/23 and 03/02/23 and Dietary #180 failed to attend either clinic to receive a vaccination injection. The DON confirmed Dietary #180 did not have either a medical or a religious exemption on file at the facility. The DON stated Dietary #180 was informed she was required to attend the vaccination clinic on 03/16/23 or she would be removed from the schedule. Review of the facility policy, COVID-19 Staff Vaccine Mandate, undated, revealed the policy stated, it is the facility's policy to require all staff to be fully vaccinated against COVID-19 in accordance with the Centers for Medicare & Medicaid Services' COVID-19 rules (Vaccine Mandate). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365794 If continuation sheet Page 32 of 32