Inspection·June 13, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a care plan was updated to include dental needs after teeth extractions. This affected one (#23) of one resident reviewed for dental. The facility census was 95. Findings include: Review of medical record for Resident #23 revealed admission date of 08/01/17, with diagnoses including osteoarthritis, spondylolisthesis cervical region, insomnia, restless leg syndrome, senile degeneration of brain, and hypertension. Review of nursing oral assessment dated [DATE] revealed Resident #23 had her own teeth and the resident recently had all her top teeth removed. Some scant bleeding and swelling remained. Bottom teeth intact in fair condition. Review of progress note dated 05/11/24 revealed Resident #23 complained of pain post dental teeth extraction. Bruises noted to face/bilateral cheeks and bruises under nose were noted. New order received to monitor bruises to face and right side until resolved. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed a brief interview of mental status (BIMS) score of 15, which indicated the resident was cognitively intact. No chewing or swallowing difficulty, weight loss, or mouth/facial pain noted during the look back period. Resident #23 was set up assist for meals. Review of care plan dated 05/29/24 revealed no care plan related to dental issues was noted. Review of oral intake for the past 14 days (05/27/24-06/10/24) revealed the resident ate on average 76-100 percent of meals. Interview on 06/10/24 at 10:59 A.M., with Resident #23 revealed the dentist took all her teeth out on the top and she had not received her dentures yet. Resident #23 stated it would be sometime in July when the fit her for dentures. Interview on 06/13/24 at 12:44 P.M., with Director of Nursing (DON) verified the care plan for Resident #23 did not include anything regarding the residents top teeth being pulled or that the residents top teeth had started breaking and they needed to be pulled. DON stated that multiple nurses did the care plans. DON verified no specific care plan regarding the resident's teeth after the teeth were pulled. Review of policy titled Comprehensive Person-Centered Care Plans revised August 2019, revealed an individualized comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The comprehensive, person-centered care plan will incorporate identified problem areas, aid in preventing or reducing decline in the resident's functional status or functional levels. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. The Interdisciplinary Team must review and update the care plan at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 2 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0657 least quarterly, and when there has been a significant change in the resident's condition. 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: 365864 If continuation sheet Page 3 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 observation, medical record review, review of the incident log, review of fall investigation, resident interview, and staff interview, the facility failed to safely transport a resident resulting in a fall. This affected one (#13) of five residents reviewed for falls. The current census is 95. Findings include: Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #13 included epilepsy, diabetes type two, obesity, heart disease, kidney disease, and osteoarthritis. Review of Resident #13's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident has intact cognition, requires a wheelchair for ambulation, and is fall risk. Review of Resident #13's care plans dated 07/11/17, with a revision on 06/21/23, revealed a focus for falls characterized by multiple risk factors. Interventions include education for resident to not transfer to a golf cart, educate resident to ask for assistance, non-skid footwear at all times, educate resident to use handrails, ensure adaptive equipment in place when resident in wheelchair, and transfer or change position slowly. Review of the incident log dated from January 2024 to June 2024 revealed there was no documented fall for Resident #13 on 05/30/24. Review of the facility's fall investigation dated 05/30/24 revealed Resident #13 reported to the staff she fell forward out of the wheelchair during transport and scraped her knees. Per the investigation the driver of the vehicle was interviewed and stated the seatbelt was not secured properly due to the resident falling onto her knees and the floor of the vehicle when the driver put on the brakes of the vehicle. Per the investigation the driver claimed he hit his head on the back hitch of the vehicle just prior to transporting the resident. The driver was educated to not drive if injured and to notify the facility for assistance. No notification of the family representative was documented in the investigation. Review of Resident #13's skin assessments dated 05/30/24 revealed the resident had scrapes on bilateral knees. Per the skin assessment dated [DATE] the injuries to the knees have healed. Observation on 06/11/24 at 3:00 P.M., of Resident #13's bilateral knees revealed no injuries were visible. Interview on 06/11/24 at 3:00 P.M., with Resident #13 revealed the resident was alert and oriented and able to recall details of past events. Resident #13 reported during a transport to an outside physician appointment the resident claimed the staff did not secure her in the transportation vehicle properly. Resident #13 stated she fell twice during the transport. Resident #13 stated she started to fall forward and was able to catch herself the first time and she yelled at the transport driver to help her since she was not 'buckled in'. Resident #13 stated the driver ignored her requests for help. Resident #13 stated the second time she fell she landed in front of her wheelchair on the floor of the transport vehicle. Resident #13 stated she hurt her knees and she again started yelling for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 4 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 help to the driver. Resident #13 stated when she arrived back to the facility she reported the fall in the bus to her nurse and the Director of Nursing (DON). Resident #13 state the DON offered her to have a x-ray of her knees but the resident declined stating she didn't think anything was broken just 'bruised'. Resident #13 denied any pain from the injuries and stated she had no further concerns regarding the fall. Interview on 06/12/24 at 11:05 A.M., with the DON verified Resident #13 reported she had fallen out of her wheelchair during transport. DON verified the driver claimed he hit his head prior to driving the resident to her appointment in the facility's vehicle. The DON stated the driver had not ensured the seatbelt was buckled due to him hitting his head prior to driving. The DON stated the driver was educated not to drive if injured. Per the DON, Resident #13's family was not notified as she is her own person and first contact for emergencies. Per the DON no other education had been provided to the driver or other staff to prevent another incident. Interview on 06/13/24 at 11:10 A.M., with State Tested Nurse Aide (STNA) #854 revealed he was driving the bus on 05/30/24, when Resident #13 had her fall. STNA #854 stated he was securing the resident into the vehicle to transport her back to the facility when he struck his head on a bar in the bus. STNA #854 stated he could not recall buckling the resident's seatbelt. STNA #854 denied hearing Resident #13 yell to him before she had fallen out of the wheelchair. STNA #854 confirmed the resident had fallen out of her wheelchair as he was pulling into the parking lot and stated he parked the vehicle at the front door and ran to get help for Resident #13. STNA #854 stated he has been educated to not drive the vehicle if he has struck his head but stated he felt he was able to continue the transport back to the facility. STNA #854 stated it is procedure to ensure all residents are secure in the vehicle prior to transporting them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 5 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to ensure all pharmacist recommendations were completed in regards to antipsychotic medication assessments. This affected one (#21) of three residents reviewed for antipsychotic medication use. The current census is 95. Findings include: Review of the medical record for Resident #21 revealed the resident was admitted to facility on 06/30/21. Diagnoses for Resident #21 include polymyalgia, spinal stenosis, bipolar disorder, degeneration of brain, and heart failure. Review of Resident #21's care plans dated 11/05/21 revealed a focus for use of antipsychotic medications related to bipolar disorder. Interventions include consult pharmacy for medication recommendation, monitor and report side effects, and monitor and record target behaviors. Review of Resident #21's prescribed medications revealed on 09/14/22 the resident is to receive Risperidone 1 milligrams (mg) (antipsychotic) daily for bipolar disorder. Review of the pharmacy's recommendations dated 08/08/23 and 11/10/23 revealed the pharmacist communicated to the nursing staff the resident was to have an Abnormal Involuntary Movement Scale (AIMS) assessment completed for the Risperidone. Review of the assessments for Resident #21 revealed on 12/20/23 and 01/17/23 an AIMS assessment had been completed for the use of antipsychotics. Interview on 06/12/24 at 3:30 P.M., with the Director of Nursing (DON) revealed per pharmacy recommendations and standards of practice AIMS assessments are to be completed quarterly for all residents on antipsychotic medications. The DON verified there was only one AIMs assessment completed for the first quarter of 2023 and one AIMS assessment completed in the fourth quarter for Resident #21. The DON verified the nursing staff did not follow the pharmacist's recommendations for the AIMS to be completed in August 2023 and November 2023. The DON verified there was no actual policy for the AIMS but stated it was a standard of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 6 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, infection control log review, and staff interview, the facility failed to ensure there was no unnecessary medications administered to residents. This affected two (#13 and #72) of five residents reviewed for unnecessary medications. The current census is 95. Residents Affected - Few Findings include: Record review for Resident #13 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #13 include epilepsy, diabetes type two, obesity, heart disease, kidney disease, and osteoarthritis. Review of Resident #13's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident has intact cognition, was receiving an antibiotic, and is fall risk. Review of Resident #13's care plans dated 07/11/17, with a revision on 01/20/22, revealed a focus for urinary tract infections. Interventions include administer antibiotics per order, monitor laboratory results, and monitor for signs and symptoms of infection. Review of Resident #13's physician orders dated 06/23/23, revealed the resident was to receive Macrobid 100 milligram (mg) (antibiotic) one time a day for recurrent urinary tract infections. Review of the infection control log from May 2023 to May 2024 revealed Resident #13 was not on the infection control log for a urinary tract infection. Interview on 06/13/24 at 1:30 P.M., with the Director of Nursing (DON) revealed Resident #13's physician had prescribed the Macrobid antibiotic as a prophylactic medication to prevent further urinary tract infections. Per the DON, Resident #13 did not have any signs or symptoms of infection which would justify the use of the antibiotic. The DON verified the physician's prescribed antibiotic did not meet the criteria for administration in regards to the antibiotic stewardship protocols. 2. Record review of Resident #72 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #72 included dementia, kidney disease, diabetes type two, failure to thrive, and urgency of urine. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a person assist for Activities of Daily (ADL). Review of Resident #72's care plans dated 10/20/23 revealed a focus for urinary tract infections. Interventions include administer antibiotics per order, monitor lab results, and monitor for signs and symptoms of infection. Review of Resident #13's physician orders dated 12/23/23 revealed the resident was to receive Cephalexin 500 (mg) (antibiotic) one time a day for recurrent urinary tract infections. Review of the facility's infection control log from January 2024 to May 2024 revealed Resident #72 was not on the infection control log for a urinary tract infection. Interview on 06/13/24 at 1:30 P.M., with the Director of Nursing (DON) revealed Resident #72's physician had prescribed the Macrobid antibiotic as a prophylactic medication to prevent further urinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 7 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 - Minimal harm or potential for actual harm tract infections. Per the DON, Resident #72 did not have any signs or symptoms of infection which would justify the use of the antibiotic. The DON verified the physician's prescribed antibiotic did not meet the criteria for administration in regards to the antibiotic stewardship protocols. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 8 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, staff interviews, and review of email communications, the facility failed to ensure pharmacy recommendations were retained and provided to the physician for Gradual Dose Reductions (GDRs) and laboratory recommendations. This affected one (#22) of five residents reviewed for unnecessary medications. The facility census was 95. Findings include: Record review revealed Resident #22 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, unspecified, dementia, and vascular dementia, unspecified severity, with other behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated 03/08424 revealed the resident had severe cognitive impairment. Review of the Care Plan dated 05/18/23 revealed resident has impaired cognitive function/impaired thought processes r/t unspecified dementia with psychotic disturbances. Resident requires partial assistance with eating, bed mobility, and wheelchair mobility and was dependent with oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and transfers. Review of the Care Plan dated 04/29/22 revealed interventions include encourage to take medication stating: the doctor wants you to take this and completing medication regimen review. Review of physician orders revealed an order dated 06/04/23, for QUEtiapine Fumarate Tablet 25 milligram (mg), give 0.5 tablet by mouth two times a day for dementia with behavioral disturbances and an order dated 07/08/23, for Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for dementia in other diseases classified elsewhere, unspecified with behavioral disturbance. Review of the Monthly Pharmacy Review received via email 06/12/24 at 9:01 A.M., revealed a pharmacy recommendation was made on 09/06/23. Per the email, the spreadsheet from the pharmacist, the pharmacy asked for a dose reduction on the Quetiapine 12.5 mg two times daily. The pharmacist recommended a depakote level be drawn. The pharmacist indicated there was no follow up on the recommendation. Interview on 06/12/24 at 4:05 P.M., with the Director of Nursing (DON) revealed the physician was in the building and advised she should not order a Depakote level due to medication being used for behaviors, not seizures. DON also advised GDR request from pharmacy dated 09/06/23, for QUEtiapine Fumarate Tablet 25 mg is not available but they would keep looking. Review of an email received on 06/13/24 at 11:02 A.M., to the DON from the pharmacy, advising the facility was not able to locate the GDR request from pharmacy dated 09/06/23 for QUEtiapine Fumarate Tablet 25 mg give 0.5 tablet by mouth two times a day. The DON verified the pharmacy made recommendations but the facility was unable to locate the recommendations. Review of the undated policy titled Pharmacy Services Overview, revealed Memorial [NAME] shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 9 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director to: Help the facility to establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 10 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, cleaning schedule review, and policy reviews, the facility failed to date food items in the walk-cooler, dispose of out of date food items, maintain the kitchen in a clean condition, obtain the correct sanitizer test strips, and properly sanitize dishware and utensils. This had the potential to affect all 95 residents who reside in the facility. The facility census was 95. Findings include: Observation on 06/10/24 at 8:58 A.M., with Executive Chef #744, of the soda dispenser revealed the machine was dirty on the inside and the holder was also dirty. Interview on 06/10/24 at 8:58 A.M., with Executive Chef #744 revealed the soda dispenser unit didn't get cleaned this weekend. Observation on 06/10/24 at 9:00 A.M., with Executive Chef #744 of the coffee station revealed the coffee machine had a brown powder under and around the dispensers and dried liquid drippings on the lids next to the dispenser. Interview on 06/10/24 at 9:00 A.M., with Executive Chef #744 revealed the coffee station is not clean. Observation on 06/10/24 at 9:06 A.M. to 9:08 A.M., with Executive Chef #744, of the the walk-in cooler revealed a container of macaroni salad did not have a date on it; a container holding a white pudding substance and orange slices did not have a date on it; and two unmarked and unlabeled plastic shopping bags containing food items were stored on a food storage cart next to a container of mushrooms, a container of cream of mushroom soup, a container of mashed potatoes, and a bag of leftover salad. Interview on 06/10/24 at 9:06 A.M., with Executive Chef #744 revealed there was not a date on the container and the macaroni salad was made last Thursday, The container holding the white pudding substance and orange slices as orange fluff. Executive Chef #744 confirmed it does not have a date and does not remember having it on the menu. Executive Chef #744 revealed the unmarked bags were stuff someone brought from home. Observation on 06/10/24 at 9:18 A.M., with Executive Chef #744 revealed the floor between the steam table and wall had a straw, sour cream container, and napkins on the ground; the floor between the ovens and grill and the wall had a burger and can of soda on the ground. Interview on 06/10/24 at 9:18 A.M. and 9:20 A.M., with Executive Chef #744 confirmed the debris and that they clean behind equipment once a week. Observation on 06/10/24 at 9:20 A.M. with Executive Chef #744 revealed the floor between the ovens and grill and the wall had a burger and can of soda on the ground. and revealed Sous Chef #834 dropped a burger behind the grill yesterday. Observation on 06/10/24 at 9:23 A.M. with Executive Chef #744, of the three compartment sink (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 11 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 revealed the test strips used to measure the sanitizer concentration are pH test strips. Level of Harm - Minimal harm or potential for actual harm Interview on 06/10/24 at 9:23 A.M., with Executive Chef #744 revealed the facility uses quat sanitizer in the sanitizer compartment of the three compartment sink. When questioned if the facility has quat test strips, Executive Chef #744 stated No, these are what I got in. Executive Chef #744 revealed the supplier gave him these test strips this past Thursday. Residents Affected - Many Observation on 06/10/24 at 9:27 A.M., with Executive Chef #744, of the dishwasher revealed the readout read ERR too hot. Also, the gauges on the machine did not move when the dishwasher was on. Observation on 06/10/24 at 9:31 A.M., revealed Executive Chef #744 used a temperature test sticker to test the hot water sanitizer of the machine. The temperature test sticker stated Square turns black as temperature is reached 160 F After running the sticker through the machine, the sticker was white. Observation on 06/10/24 at 9:33 A.M., revealed the temperature test sticker was ran through the dishwasher again by Executive Chef #744. Interview on 06/10/24 at 9:33 A.M., with Executive Chef #744 revealed the second test strip did not reach appropriate temperature either. When questioned what is the process if the dishwasher isn't working, Executive Chef #744 revealed they handwash everything then. Observation on 06/10/24 at 9:43 A.M., with Executive Chef #744, of the dry storage revealed three outdated bags of [NAME] big white bread amongst many other bags of bread stored on the bread rack in the kitchen. There were bags dated May 27, 2024; May 31, 2024; and June 6, 2024. Interview on 06/10/24 at 9:43 A.M., with Executive Chef #744 revealed the bread must have gotten mixed up. Executive Chef #744 stated they get bread twice a week. Observation on 06/11/24 at 3:24 P.M., revealed the soda can and debris is still on the ground behind the ovens and grill and there are still napkins, a sour cream container, and a straw on the ground behind the steam table. Interview on 06/11/24 at 3:45 P.M. with Executive Chef #744 revealed the dishwasher is not fixed. Executive Chef #744 revealed someone came to look at the dishwasher last night. Executive Chef #744 revealed he was under the impression the dishwasher was fixed as no one called or told them about it. Executive Chef #744 revealed he put a temperature sticker through the machine after breakfast and the machine was still not working. Executive Chef #744 said they have been handwashing since breakfast. Executive Chef #744 called the company and they said they had to order a part because they didn't have it on hand. When asked if they are still using the dishwasher, Executive Chef #744 said they are running large items through the dishwasher that do not fit in the three compartment sink. Executive Chef #744 said they still do not have correct sanitizer test strips. When asked how are you making sure dishes and utensils are being sanitized, Executive Chef #744 said that is a good question and he hopes that the sanitizer is right. Interview on 06/11/24 at 4:35 P.M. with Executive Chef #744 confirmed the dishwasher is a high temperature sanitizer dish machine. Executive Chef #744 revealed he ordered the proper sanitizer test strips and a dishwasher thermometer because the gauges on the dishwasher do not move and the electronic read out is an error message. Executive Chef #744 revealed they currently do not have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 12 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 appropriate test strips for the three compartment sink. Level of Harm - Minimal harm or potential for actual harm Interview on 06/11/24 at 4:44 P.M., with Executive Chef #744 revealed there is still trash behind equipment on both walls. Executive Chef #744 picked up the soda can. Residents Affected - Many Interview on 06/13/24 at 10:35 A.M., with the Administrator revealed the facility does not have a policy for where employees are to store their food. Interview on 06/13/24 at 10:49 A.M., with Executive Chef #744 revealed they do not keep a temperature log of each dish machine cycle, but he does keep a log of daily test stickers. The test sticker log starts 01/01/24 and ends 05/04/24. Executive Chef #744 revealed he ran out of stickers at that time. Review of undated cleaning schedule revealed the coffee machine table and floors under equipment on the line are cleaned monthly. Review of the policy titled, Food and Nutrition Services, dated April 2023, stated the facility will dispose of garbage and refuse properly, garbage and refuse containers will be maintained in good condition, and garbage receptacles will be covered when transported to the dumpster from the kitchen. Review of the policy titled, Dishwashing Machine Use, dated April 2020, stated dishwashing machine hot water sanitation rinse temperatures may not be more than 194°F, or less than: 165°F for stationary rack, single temperature machines. The policy also stated corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the super-visor and corrected immediately. Lastly, the policy stated If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. Review of the policy titled, Refrigerators and Freezer,dated April 2023 revealed all food shall be appropriately dated to ensure proper rotation by expiration dates. The policy also stated supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Review of the policy titled, Food Receiving and Storage Policy, dated April 2020 stated all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Review of the undated policy titled, Multi-Quat Sanitizer, revealed Keystone multi-quat sanitizer is a concentrated, no rinse quat sanitizer that is effective across a dilution range of 0.26 - 0.68 oz per gallon of water. The policy also revealed that the quat range for use is 150-400 parts per million. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 13 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and policy review, the facility failed to ensure the dishwasher was maintained in working order. This had the potential to affect all 95 residents who reside in the facility. The facility census was 95. Residents Affected - Many Findings include: Observation on 06/10/24 at 9:27 A.M., with Executive Chef #744 revealed the dishwasher had an electronic read out that states ERR too hot when it was running. Also, the gauges on the dishwasher were not moving while the machine was on. Interview on 06/10/24 at 9:27 A.M., with Executive Chef #744 revealed the facility has a high temperature sanitizing dishwasher. Executive Chef #744 also said he is looking for a high temperature of 185 to 190 degrees Fahrenheit (F). Observation on 06/10/24 at 9:31 A.M., revealed Executive Chef #744 used a temperature test sticker to test the hot water sanitizer of the machine. The temperature test sticker stated Square turns black as temperature is reached 160 F. After running the sticker through the machine, the sticker was white. Observation on 06/10/24 at 9:33 A.M., revealed the temperature test sticker was ran through the dishwasher again by Executive Chef #744. Interview on 06/10/24 at 9:33 A.M., with Executive Chef #744 revealed the second test strip did not reach appropriate temperature either. When questioned what is the process if the dishwasher isn't working, Executive Chef #744 revealed they handwash everything then. Interview on 06/11/24 at 3:45 P.M., with Executive Chef #744 revealed the dishwasher is not fixed. Executive Chef #744 revealed someone from GFS came to look at the dishwasher last night. Executive Chef #744 revealed he was under the impression the dishwasher was fixed as no one called or told them about it. Executive Chef #744 revealed he put a temperature sticker through the machine after breakfast and the machine was still not working. Executive Chef #744 said they have been handwashing since breakfast. Executive Chef #744 called the company and they said they had to order a part because they didn't have it on hand. When asked if they are still using the dishwasher, Executive Chef #744 said they are running large items through the dishwasher that do not fit in the three compartment sink. Executive Chef #744 said they still do not have correct sanitizer test strips. When asked how are you making sure dishes and utensils are being sanitized, Executive Chef #744 said that is a good question and he hopes that the sanitizer is right. Interview on 06/11/24 at 4:35 P.M., with Executive Chef #744 confirmed the dishwasher is a high temperature sanitizer dish machine. Executive Chef #744 revealed he ordered the proper sanitizer test strips and a dishwasher thermometer because the gauges on the dishwasher do not move and the electronic read out is an error message. Interview on 06/13/24 at 10:49 A.M. ,with Executive Chef #744 revealed they do not keep a temperature log of each dish machine cycle, but he does keep a log of daily test stickers. The test sticker log starts 01/01/24 and ends 05/04/24. Executive Chef #744 revealed he ran out of stickers at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365864 If continuation sheet Page 14 of 15 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 365864 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gables of Marysville Health and Rehabilitation 390 Gables Drive Marysville, OH 43040 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy titled, Dishwashing Machine Use, dated April 2020 stated dishwashing machine hot water sanitation rinse temperatures may not be more than 194°F, or less than: 165°F for stationary rack, single temperature machines. The policy also stated corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the super-visor and corrected immediately. Lastly, the policy stated if hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. Event ID: Facility ID: 365864 If continuation sheet Page 15 of 15