Inspection·April 25, 2019

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the Institute of Safe Medication Practices and staff interview, the facility nurse failed to meet professional standards during routine medication administration when the nurse used another resident's medication when a medication was not immediately available. This affected one (#38) of five residents observed during medication pass. (Resident #38) Residents Affected - Few Findings include: Observation on 04/24/19 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #116 prepared the medications for Resident #38. When he came to the Divalproex (anticonvulsant) 125 milligram (mg.) medication, he stated it was not available in the cart. He stated he would borrow the medication from Resident #51 and then after he was finished passing morning medications, he would get the medication from the emergency drug kit (EDK) box and return his dose. He proceeded to use Resident #51's medication to administer to Resident #38. Interview on 04/24/19 at 9:15 A.M. with Licensed Practical Nurse (LPN) #2 stated the nurses were not ever to borrow medications from another resident. She stated we have a EDK box to get medications from or if there was none available in there, the nurse should call the pharmacy to get it delivered and then call the physician if the time of administration would change. LPN #3 who was present at the time of the interview, agreed the nurse were not supposed to borrow medications from other residents. Review of the Institute for Safe Medication Practices, dated 11/19/09, revealed borrowing medications as a workaround to speed the process of administering medications due to inherent or excessive wait times associated with the pharmacy dispensing process, increases the risk of an error and are not accepted clinical standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 2 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 ensure resident falls were thoroughly reviewed to implement relevant interventions and failed to implement fall interventions per the resident's care plan. This affected two (Resident #56 and Resident #76) of five resident reviewed for accidents. The census was 97. Findings Include: 1. Record review for Resident #56 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavioral disturbances, muscle weakness, difficulty walking, postpolio syndrome, anxiety disorder, and mid-cervical disc disorder. Review of the Brief Interview for Mental Status (BIMS) assessment, dated 02/19/19, revealed the resident was severely cognitively impaired. Review of Resident #56 medical records revealed she had an unwitnessed fall on 01/28/19. She was assessed and sent to the emergency room (ER) for evaluation, which determined she had a fractured arm. In review of the fall incident report and medical documentation, there was no evidence that the cause of the fall was attempted to be determined. In review of her plan of care, she had a focus area related to the risk of falling. But after her fall on 01/28/19, the only addition to the interventions of this care plan was, x-ray, sent out to ER for evaluation. There was no new intervention implemented after the resident returned from the ER. 2. Record review for Resident #76 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, difficulty walking, lack of coordination, muscle weakness, other symbolic dysfunctions, cerebral infarction and insomnia. Review of her BIMS assessment score, dated 03/22/19, revealed she was severely cognitively impaired. Review of Resident #76 medical records revealed she had a fall on 03/05/19. She was assessed and an x-ray was ordered due to pain. It was determined she had a hip fracture, which then she was sent to the ER. In review of the fall incident report and medical documentation, there was no evidence that the cause of the fall was attempted to be determined. In review of her plan of care, she had a focus area related to the risk of falling. But after her fall on 03/05/19, the only addition to the interventions of this care plan was, send to ER, patient for evaluation and treatment when return. Also, she had a fall on 04/04/19 in which the fall incident report and medical documentation did not attempt to determine the cause of the fall other than saying she was observed on the floor near the bathroom in her room. After this fall, the plan of care interventions were not updated to assist with preventing future falls; the only intervention added was to get an x-ray completed and send her to the ER. Interviews with Director of Nursing (DON) and Licensed Practical Nurse (LPN) #3 on 04/24/19 at 12:38 P.M. and 2:33 P.M. revealed the facility documentation to determine a cause for the falls was lacking. They confirmed the only interventions added for both of these falls were immediate actions and not anything to prevent the falls from occurring again. They confirmed they do not know what caused the falls so they were not able to put those interventions in place. They both confirmed they need to gather that information in the future. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 3 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy titled Fall Evaluation, dated August 2016, revealed the staff will identify environmental factors that may contribute to falling, such as lighting and room layout; and the staff, in conjunction with the attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. Review of the facility policy on Falls/Fall Risk Management, dated August 2016 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. It also stated the staff, with the input from the attending physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risks identifies several possible interventions, the staff may choose to prioritize the interventions (i.e. to try one or a few at a time, rather than many at once.) If falling recurs despite initial interventions, staff will implement additional or different interventions, or or indicate why the current approach remains relevant. Event ID: Facility ID: 365839 If continuation sheet Page 4 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation and staff interview, the facility failed to provide routine medications for resident when a medication was not available during medication administration. This affected one (#38) of five residents observed during medication pass. The facility census was 97. Findings include: Observation on 04/24/19 at 8:14 A.M. revealed Licensed Practical Nurse (LPN) #116 prepared the medications for Resident #38. When he came to the Divalproex (anticonvulsant) 125 milligram (mg.) medication, he stated it was not available in the cart. He stated he would borrow the medication from Resident #51, and then after he was finished passing morning medications, he would get the medication from the emergency drug kit (EDK) box and return his dose. He proceeded to use Resident #51's medication to administer to Resident #38. Interview on 04/24/19 at 9:15 A.M. with Licensed Practical Nurse (LPN) #2 stated the nurses were not ever to borrow medications from another resident. She stated they have a EDK box to get medications from or if there was none available in there, the nurse should call the pharmacy to get it delivered and then call the physician if the time of administration would change. LPN #3 who was present at the time of the interview, agreed the nurses were not supposed to borrow medications from other residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 5 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 - Few 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. Based on medical record review and staff interview, the facility failed to provide the appropriate diagnosis for the use of an antipsychotic medication. This affected one (Resident #51) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: A medical record review for Resident #51 revealed an admission date of 01/30/18. Diagnoses included dementia with behavioral disturbance, aphasia, unspecified psychosis, conversion disorder with seizures, heart failure, major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/07/19, revealed Resident #51 had severe cognitive impairment and required limited assistance for his daily care from the staff. Review of the current physician's order set for Resident #51, dated 04/2019, revealed an order Seroquel (an antipsychotic medication) 75 milligrams (mg.) by mouth every night for insomnia. In addition, Depakote (an antipsychotic) 500 mg. by mouth at 10:00 A.M. and 2:00 P.M. and 750 mg at 10:00 P.M. for the diagnosis of wanting to leave. On 04/25/19 at 1:48 P.M., an interview with the Director of Nursing (DON) confirmed Resident #51 did not have a diagnosis of insomnia. The DON also verified the physician had signed the 04/2019 order sheet verifying the diagnoses of insomnia list for Seroquel and wanting to leave as the diagnosis for Depakote. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 6 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, staff interview and review of the policy and procedure for medication administration, the facility failed to ensure their medication error rate was less than 5% as three medication errors were noted out of 29 opportunities for a medication error rate of 10.34%. This affected three (Resident #22, #38 and #53) of five residents observed for medication administration. Residents Affected - Few Findings include: 1. Observation on 04/24/19 at 8:14 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #116 prepared medications for Resident #38. The medications were prepared and taken to the room of Resident #38. The resident was standing at the bathroom door at the time the nurse entered the room. He handed the resident his medications and the resident placed the medications in his mouth from the medication cup, dropping one on the floor. The nurse picked up the dropped pill and disposed of it. He then went on to pass medications to the next resident. The nurse was not observed identifying the pill prior to disposing of it. The nurse did not bring a replacement pill to the resident. 2. Continued observation of LPN #116 passing medications to Resident #53 at which time he prepared the medications on 04/24/19 at 8:27 A.M. He prepared Calcium 600 mg. with Vitamin D 400 I.U., Donepezil (can treat Alzheimer's disease) five mg., multivitamin tablet and Midodrine (blood pressure support) 2.5 mg. which he administered to Resident #53. The physician's orders were reviewed and revealed Famotidine (heartburn relief) 10 mg. was not observed to be given, even though it was ordered to be given with the morning medications. Interview with LPN #116 on 04/24/19 at 9:25 A.M. verified he didn't give Resident #53's Famotidine because it was not available and had circled it as not given on the medication administration record (MAR). He stated he was going to get it from the EDK (emergency drug kit) and give it now. The nurse later provided the bottle for the medication he gave. The bottle contained Ranitidine 75 mg. which he stated was a stock medication he got from another unit because the EDK didn't have the correct dose. He had signed this off on the Medication Administration Record that he gave the Famotidine. He confirmed the medication he gave (Ranitidine 75 mg.) was not the same medication and/or dose that was ordered. He also stated he took Resident #38's dropped pill to him later. He verified this was not documented and/or the pill was not identified prior to disposing of it. 3. Observation on 04/24/19 at 8:41 A.M. with Registered Nurse (RN) #102 revealed the nurse prepared medications for Resident #22. Oyster shell calcium 500 mg plus D3 200 was given. Reviewing the current physician's orders revealed the order was for Oyster shell calcium. The order did not include the Vitamin D. The resident takes vitamin D 2000 units as a separate medication. This was confirmed on 04/24/19 at 9:22 A.M. when the RN #102 stated the only oyster shell calcium she had available to her was the one that contained Vitamin D. Review of the policy and procedure for medication administration revealed the facility staff understands and observes the six rights, concepts of medication administration, right drug, right resident, right time, right dose, right form through the right route. Medication administration records are utilized during a medication pass to verify that the medication name and dose and directions on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 7 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 0759 medication label match the medication order transcribed to the MAR. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 8 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, staff interviews and review of the facility's policies, the facility failed to ensure the storage of frozen and refrigerated foods in a manner to protect against spoilage. The facility also failed to ensure the staff washed their hands moving from dirty dishes to touching clean dishes. In addition, the facility failed to ensure the temperature of the hamburgers served at lunch, had been cooked to the appropriate temperature. This had the potential to affect all 97 residents who received food from the kitchen. The facility census was 97. Findings include: 1. On 04/22/19 between 8:25 A.M and 9:00 A.M., a tour of the kitchen was conducted with the Dietary Manager (DM) #1. Observation of the walk-in refrigerator revealed a large plastic container, covered with foil, containing an orange pureed substance. The container was dated but had no label. Observation of the walk-in freezer revealed one plastic bag with breaded meat patties with no label and open to air. Another bag containing several large pieces of light-colored meat, had no label. Observations also revealed one bag of diced meat, a box of chicken Cordon Blue, one bag of French bread pizza and a bag of French toast, all with no label or dates. On 04/22/19 at 9:00 A.M., DM #1 confirmed the above observations. 2. On 04/22/19 between 9:00 A.M. and 9:10 A.M., observation of [NAME] #29 wearing disposable gloves while rinsing off dirty pots and pans. [NAME] #29 was observed moving from the clean to the dirty side of the dish washer to remove a cleaned rack of water glasses. She then moved back to the dirty side of the dish washer and continued to rinse off dirty dishes and pans. She again was observed to move to the clean side of the dishwasher and removed a clean rack filled with pots and pan. [NAME] #29 was observed to take these items off the rack and put them away. [NAME] #29 was observed to move from the dirty to the clean side of the dish washer a total of six times. At no point was [NAME] #29 observed to change her gloves or wash her hands. On 04/22/19 at 9:12 A.M., in an interview with [NAME] #29, she confirmed she had not change her gloves or washed her hands throughout washing her pots and pans or taking them out of the dishwasher and putting them away. On 04/22/19 at 9:20 A.M., the above observations were shared with DM #1. 3. On 04/23/19 at 11:05 A.M,. Kitchen Staff #120 was observed rinsing off dirty dishes. He was then observed to move to the clean side of the dishwasher and removed a cleaned rack of dishes and put them away. He was observed not wearing disposable gloves nor had he washed his hands before touching the cleaned dishes. On 04/23/19 at 11:07 A.M., in an interview with Kitchen Staff #120, he denied moving from the dirty to the clean side of the dishwasher or touching the cleaned dishware with his bare hands. On 04/23/19 at 11:10 A.M. Kitchen Staff #120 was observed to wash his hands and put on disposable gloves. On 04/23/19 at 11:20 A.M. in an interview with DM #1, the surveyors' observations were shared with the DM. She stated she would do more education. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 9 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. On 04/25/19 at 12:00 P.M., lunch service was observed to have started. Several resident plates had been prepared. The steam table food temperatures were then taken after surveyor intervention. On 04/25/19 at 12:35 P.M., in an interview with [NAME] #29, she was asked what the final cooking temperature of the meal's hamburgers, being served, had been. [NAME] #29 stated she had not taken the final cooked temperature of any item currently being served. [NAME] #29 confirmed she had not taken the cooked temperature of the hamburgers. On 04/25/19 at 12:45 P.M., in an interview with DM #1, she stated the burgers came frozen and uncooked. DM #1 and the surveyor then observed a hamburger taken from the steam table and the DM #1 verified it appeared to be cooked. The DM #1 also verified all 97 residents had been served the hamburgers. On 04/25/19 at 12:55 P.M., in an interview with Dietitian Technician #125, she confirmed she did not know the policy concerning food temperatures not taken or reaching the desired final cooking temperature. Review of the final cooking temperature logs, dated 04/21/19 through 04/24/19 revealed the final cooked temperature of hot had been taken and were appropriate. No documentation was available for 04/25/19. Review of the facility's undated policy titled Frozen Storage revealed all frozen products shall be labeled indicating the product name and date of delivery. Review of the facility's undated policy titled Refrigerated Storage revealed all refrigerated items shall bear a label indicating the product name and date the product was received, used or first opened. Review of the facility's undated policy titled Date Marking revealed all foods prepared and held in refrigeration for over 24 hours, shall be clearly marked to indicate the date by which the food shall be consumed or discarded. Review of the facility's undated policy titled Hand Washing revealed all employees shall wash their hands after handling soiled equipment or utensils, and between handling soiled and clean dishes. Review of the facility's undated policy titled Recording Final Cooking Food Temperature revealed the final cooking temperatures of selected foods shall be recorded at each meal. The cook or designee is responsible for documenting the final cooking temperature of hot food items at each meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 10 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to follow infection control procedures when treating and monitoring potentially infections skin conditions. This affected three (#41, #75 and #89) of four residents reviewed for scabies. This had the ability to affect all 97 residents residing in the facility. Residents Affected - Many Findings Include: 1. Record review for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances, scabies, sepsis and pneumonia. Review of his Brief Interview for Mental Status (BIMS) assessment score, dated 01/18/19, revealed it was not completed due to his inability to answer the questions. This indicated he was severely cognitively impaired. Further review of Resident #41's medical records revealed when he was discharged from the hospital on [DATE]. In review of a physician's progress note, dated 01/16/19, revealed Resident #41 was in the hospital and was diagnosed with severe sepsis due to healthcare associated pneumonia. Along with the diagnosis, the progress note stated the course of treatment was complicated by scabies, which was managed by Permethrin cream, which was a typical treatment for actual or potential cases of scabies. There was no physician order or documentation to support this resident was placed on isolation precautions. 2. Record review for Resident #75 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease. Review of her BIMS assessment score, dated 03/18/19, revealed it was not completed due to her inability to answer the questions. This indicated she was severely cognitively impaired. Review of Resident #75 medical records revealed a physician's progress note, dated 03/21/19, that stated she was being treated for an infestation by sarcoptes scabies var hominis (scabies). She was prescribed Permethrin cream on 03/15/19 and had the treatment applied on 03/15/19 and 03/22/19. The physician's note went on to state he spoke with nursing and resident and the resident treated with Permethrin cream for possible scabies. He noted two other residents with similar rash. There was no physician order or documentation to support this resident was placed on isolation precautions. 3. Record review for Resident #89 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia without behavioral disturbances. Review of her BIMS assessment score, dated 03/25/19, revealed she was moderately cognitively impaired. Review of Resident #89 medical records revealed she had two separate dermatology appointments, dated 03/14/19 and 04/04/19). Both appointments were to address the possible diagnosis of scabies. The appointment on 03/14/19 gave a diagnosis of Scabies and Seborrheic keratosis and a prescribed treatment of or Permethrin cream. It stated the symptoms began about six months ago. The appointment on 04/04/19 revealed it was for a scabies follow up and that the symptoms began about seven months ago. There was no physician order or documentation to support this resident was placed on isolation precautions. Interviews with Minimum Data Set (MDS) Coordination #11, Unit Manager #2, Director of Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 11 of 12 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 365839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Columbus Alzheimer's Care Ctr 700 Jasonway Avenue Columbus, OH 43214 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many (DON), Environmental Services Director #5, and Administrator on 04/23/19 at 3:36 P.M., 04/24/19 at 4:26 P.M., and 04/25/19 at 11:12 A.M., 11:43 A.M., 12:18 P.M., and 12:21 P.M. revealed there were at least three residents who were identified as possibly having scabies and treatment was put in place for them. They all confirmed that no one was on contact and/or other isolation precautions. When asked to explain why, they stated with the nature of their population (residents with severe cognitive deficits and wandering tendencies), they would have to keep all staff and residents without possible scabies in gowns and gloves until they were not infectious anymore. They all stated they do not have specific protocol for keeping residents and staff safe from a scabies outbreak (if there were one). They stated the protocol they use was staff use gloves while providing direct care, they do not need to use gloves, use proper handwashing techniques, and follow physician orders for treatment. Environmental Services Director #5 stated if they would have a confirmed case of scabies (or an outbreak), they would deep clean the resident(s) rooms. He confirmed they have not deep cleaned resident rooms due to scabies for at least two years. When they deep cleaned those rooms (and subsequent deep cleanings), they use gloves, but no gowns or other protection to ensure the staff do not get scabies. DON confirmed they have not had any staff be treated for rashes, and no staff have reported any rash issues, but they do not have any other mechanism in place to ensure staff do or do not have rashes/scabies other than staff reporting. Review of facility Infection Control Logs and Documentation revealed the facility completed a Outbreak Investigation Form revealed there were five incidents of scabies documented. The form stated the dermatologist did not do a skin test to confirm scabies, but they were treating the rashes as scabies. It confirmed treatment was started for the residents, but there is no indication that any type of contact precautions were put into place. Review of the facility Infection Prevention Manual regarding Scabies, dated 2012, revealed scabies is an infestation of the skin by the human itch mite (Sarcoptes scabiei var hominus). It also lists the following as precautions if there is actual or suspected cases of scabies: contact precautions until 24 hours after initiation of effective treatment, wear gloves and gowns for all direct resident care, and avoid direct skin to skin contact with suspected or confirmed scabies cases. Treatment for this includes: topical treatment with Permethrin or oral treatment with ivermectin currently is not FDA-approved for treatment of scabies. Finally, the policy states that special considerations for the prevention and treatment of scabies includes, the facility should have an active program for early detection, treatment, and implementation of appropriate isolation and infection control practices. This deficiency substantiated Complaint Number OH00103713 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365839 If continuation sheet Page 12 of 12