Health inspection·June 13, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, and staff interview, the facility failed to ensure access to the call light for one dependent resident (Resident #27) reviewed for call lights in reach. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/24/24. Diagnoses included of metabolic encephalopathy, hemiplegia affecting right dominant side, hemiparesis following cerebral infarction affecting right dominant side, schizoaffective disorder, anxiety disorder, and hydrocephalus. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. The resident was dependent for shower/bathing, personal hygiene, and always incontinent of bowel and bladder. Observation on 06/10/24 at 11:47 A.M. revealed Resident #27 was laying in bed on their back with their call light tied to the right bedrail and hanging down from the bedrail toward the floor, inaccessible to the resident. The call light was a modified with a bulb type of activation. Interview on 06/10/24 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #408 verified the call light for Resident #37 was tied to the right bedrail of Resident #27's bed and hanging down toward the floor, and inaccessible to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Pre admission Screen and Resident Review (PASARR) forms were completed for a change of condition in mental health diagnosis. This affected one(#34) of two residents reviewed for PASARR compliance. The facility census was 67. Findings include: Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Resident #34's schizoaffective disorder diagnosis was added 07/07/23. Review of the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 was taking a scheduled antipsychotic at the time of the review. Resident #34 displayed no behaviors during the review period. Review of Resident #34's care plan, revised 03/21/24, revealed supports and interventions for impaired cognitive function, psychoactive wellbeing problem, sexual behaviors, potential to demonstrate verbally abusive behaviors, and psychotropic medication use. Review of Resident #34's Psychiatric Service Progress Note dated 07/06/23 revealed Resident #34 was seen due to an increase in paranoid delusions including visual hallucinations of someone coming in her room at night. She was not sleeping during the night due to increased paranoia and hallucinations. Resident #34's delusions were noted to be altering her perception of reality. Her delusions and paranoia were reported to be getting worse. Resident #34 received a new diagnosis of schizoaffective disorder bipolar type. Review of Resident #34's Preadmission Screening and Resident Review (PASARR) dated 06/14/21 revealed Resident #34 was ruled out due to not having a severe mental health condition, intellectual disability, or developmental disability. The determination indicated if a change occurred suggesting Resident #34 had a mental health condition, intellectual disability, or developmental disability then further evaluation was needed. Further review of Resident #34's medical record found no evidence her PASARR screening was completed following the 07/07/23 addition of her schizoaffective disorder bipolar type diagnosis. Interview on 06/11/24 with Director of Social Services (DSS) #474 revealed residents did not need another PASARR screening unless they had a significant change. DSS #474 reviewed Resident #34's diagnoses and psychological services information and verified with the addition of her schizoaffective disorder bipolar type diagnosis, paranoid delusions, and hallucinations at night a PASARR review request should have been submitted due to a significant change occurring. Review of the facility policy titled Resident Assessment Coordinate with PASARR Program, dated 06/22/22 revealed a resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples included a resident whose (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 intellectual disability or related condition was not previously identified and evaluated through the PASARR. 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: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on review of the medical record, staff interview, and policy review, the facility failed to include the use of a psychotropic medication for depression in the resident's comprehensive care plan. This affected one (#67) of three residents reviewed for care planning. The facility census was 67. Findings include Review of the medical record for Resident #67 revealed an admission date of 05/15/24. Diagnoses included systolic depressive disorder and anxiety. Review of a physician order dated 05/16/24 revealed the resident had an order for Zoloft 100 milligrams (mg) daily for depression. Review of the care plan for Resident #67 revealed there was no care plan in place for the use of a psychotropic medication for depression. Interview on 06/11/24 at 8:02 A.M., Registered Nurse (RN) #495 verified there was no plan of care in place for Resident #67's use of the psychotropic medication Zoloft for depression. Review of the policy titled Comprehensive Care Plans, dated 10/24/22, revealed the comprehensive care plan would include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 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 medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were included in the development for their plan of care and failed to have care planning meetings to periodically review the care plan. This affected two (#39 and #67) of three residents reviewed for care planning. The facility census was 67. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 04/17/24, revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating and was dependent on staff for toilet use, bathing and dressing. Resident #39 displayed no behaviors during the review period. Review of Resident #39's current care plan, revised 01/29/24, revealed supports and interventions for self-care deficit, psychoactive medication use, risk for falls, and nutritional risk. Interview on 06/10/24 at 9:28 A.M. with Resident #39 found her to be alert and aware. Resident #39 reported she had not participated in her care planning and a care planning meeting had not been held that she was aware of. Review of Resident #39's Care Conference Summary dated 11/30/23 revealed Resident #39's care plan meeting was held with Resident #39's family and facility staff but not the resident. This care plan meeting was held seven months prior and there was no evidence of a quarterly care plan meeting being held. Interview on 06/11/24 at 8:48 A.M. with Director of Social Services (DSS) #474 verified there was no information indicating Resident #39 participated in a care planning meeting. Follow up interview with DSS #474 on 06/11/24 at 10:33 A.M. verified Resident #474's last care planning meeting was held on 11/30/23. DSS #474 stated care planning meetings were to be held seven to ten days of admission, quarterly and if there was a significant change. DSS #474 verified Resident #39's quarterly care planning meeting had not been held. 2. Review of the medical record for Resident #67 revealed an admission date of 05/15/24. Diagnoses included systolic heart failure, hypertension, atrial fibrillation, depressive disorder, anxiety, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the medical record revealed no documentation the resident had participated in a care plan conference meeting since admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 Level of Harm - Minimal harm or potential for actual harm Interview on 06/10/24 at 9:18 A.M., Resident #67 revealed he had not had a care plan meeting since his admission. Interview on 06/11/24 at 8:02 A.M., Registered Nurse (RN) #495 verified there was no documentation the resident had a care plan conference since admission. Residents Affected - Few Interview on 06/11/24 at 10:33 A.M., the DSS #474 revealed care plan meetings should be held upon admission, quarterly, and with significant changes in condition. Review of the policy titled Care Planning--Resident Participation, dated 02/27/23, revealed the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conference, and allow them to see the care plan, initially, at routine intervals, and after significant changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 review of facility policy, the facility failed to ensure residents were provided with scheduled grooming and bathing. This affected three (#7, #23, and #273) of seventeen residents observed for activities of daily living. The facility census was 67. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following subarachnoid hemorrhage, cirrhosis of liver, anxiety disorder, major depression, peripheral vascular disease, anemia, and non-pressure chronic ulcer to right and left foot. Review of the Minimum Data Set assessment, dated 04/25/24, revealed Resident #7 had intact cognition. Resident #7 required assistance with activities of daily living, was incontinent of urine and continent of bowel. Review of the plan of care revealed on 06/26/23 the care plan was revised to address Resident #7's activity of daily living self care performance deficit related to hemiplegia, limited mobility and end stage renal disease. Interventions included there resident prefers showers, requires assistance with personal hygiene care, dependent on staff to provide a bath as necessary, and provide with a sponge bath when a full bath or shower cannot be tolerated. Review of Resident #7's shower schedule noted routine showers scheduled every Tuesday and Saturday. The shower documentation noted between 05/07/24 and 06/11/24, out of eleven opportunities, only three showers were provided on 05/07/24, 05/14/24, and on 06/11/24. No further shower activity was documented in the medical record. Observation on 06/10/24 at 11:56 A.M. noted Resident #7 seated in a wheelchair at the bedside. The resident's hair appeared unkept and with a shiny or greasy sheen. Interview on 06/10/24 at 11:56 A.M., at the time of the observation, Resident #7 stated she did not receive routine showers as scheduled. Interview on 06/11/24 at 1:22 P.M. the Director of Nursing (DON) verified showers were not documented to be provided as scheduled for Resident #7. The DON confirmed Resident #7 was observed with greasy appearing hair. 2. Review of the medical record for Resident #23 revealed an admission date of 12/06/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominate side, need for assistance with personal care, vascular dementia, major depressive disorder, and right elbow contracture. Review of the MDS assessment, dated 04/04/24, revealed Resident #23 was severely cognitively impaired. Resident #23 required maximum assistance for showers and bathing. Review facility shower schedule revealed Resident #23 was scheduled for showers every Wednesday and Sunday on second shift. Review of the shower sheets for 05/01/24 through 06/12/24 revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0677 Level of Harm - Minimal harm or potential for actual harm #23 was scheduled to receive 13 showers. The resident only received showers on 05/01/24, 05/08/24, 05/22/24, and 05/29/24. Interview on 06/13/24 at 9:53 A.M. with the DON verified Resident #23 had only received four of the 13 scheduled showers from 05/01/2 through 06/12/24. Residents Affected - Few Review of facility policy titled Resident Showers, dated 11/17, revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 3. Review of the medical record for Resident #273 revealed an admission date of 06/01/24. Diagnoses included peripheral vascular disease, difficulty walking, osteoarthritis, hypertension, and hemiplegia and hemiparesis following cerebral vascular accident. Review of the admission Functional Abilities and Goals assessment dated [DATE] at 7:32 P.M. revealed the resident was dependent for showers and bathing. Review of the shower schedule revealed Resident #273 was scheduled for showers on Tuesdays and Fridays on day shift. Review of the medical record revealed no documentation Resident #273 had received a shower on 06/04/24 and 06/07/24. Observation on 06/10/24 at 8:53 A.M. revealed Resident #273's hair appeared unkempt. Interview on 06/10/24 8:53 A.M., Resident #273 revealed she would like her hair washed. Resident #273 stated she had not been showered since her admission to the facility. Interview on 06/11/24 at 10:31 A.M., the DON verified there was no documentation Resident #273 had received a shower. Interview on 06/12/24 at 1:48 P.M., Licensed Practical Nurse (LPN) #419 revealed Resident #273 needed her hair washed because she had a bloody nose and had blood in her hair. This deficiency represents non-compliance discovered during the investigation for Complaint Number OH00153731. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 Based on medical record review and staff interview, the facility failed to ensure residents were monitored for bowel movements and interventions for constipation were implemented as ordered. This affected three (#52, #23 and #30) of four residents reviewed for constipation. The facility census was 67. Residents Affected - Few Finding include: 1. Review of Resident #52's medical record revealed an admission date of 06/14/23. Diagnoses included type II diabetes, major depressive disorder, anxiety disorder, polyneuropathy, and insomnia. Review of the MDS assessment, dated 05/20/24, revealed Resident #52 was severely cognitively impaired. Resident #52 was dependent on staff for toilet use and bathing. Resident #52 had hallucinations, delusions, and displayed rejection of care behaviors one to three days during the review period. Review of Resident #52's care plan, revised 05/20/24, revealed supports and interventions for use of psychoactive medications with risk for constipation, urinary and bowel incontinence and risk for constipation due to decreased mobility. Interventions for constipation included encourage to drink adequate fluids, follow the facility bowel protocol for bowel management, medicate as ordered, record bowel movement pattern and monitor, document and report signs and symptoms of complications related to constipation to the physician. Review of Resident #52's Bowel and Bladder Tracking for the last 30 days revealed Resident #52 did not have a bowel movement documented from 05/22/24 until 06/07/24 for a total of 13 days with no bowel movements. No interventions were found in the record for this lack of bowl movements. Review of Resident #52's physician orders revealed an order dated 06/14/23 for docusil 100 milligrams (mg) two times a day for constipation. There was an order dated 06/15/23 for polyethylene glycol 3350 powder 17 grams (gm) once a day for constipation. Resident #52 had no as needed orders for constipation. Review of Resident #52's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the last 30 days revealed all Resident #52's scheduled medications for constipation were administered as ordered and no as needed medications were ordered or administered. Interview on 06/12/24 at 11:52 A.M. with the Director of Nursing (DON) verified there was no documentation Resident #52 had a bowel movement from 05/22/24 through 06/06/24. There was also no additional bowel interventions documented as being administered. 2. Review of the medical record for Resident #23 revealed an admission date of 12/06/19 with diagnoses of hemiplegia and hemiparesis following cerebral infarction right dominate side, dysphagia, need for assistance with personal care, abnormal posture, and vascular dementia. Review of the MDS assessment, dated 04/04/24, revealed Resident #23 was severely cognitively impaired. Further review of the MDS data revealed Resident #23 is dependent for toileting, requires maximum assistance for showers and bathing, and is incontinent of bowel and bladder. Review of orders for Resident #23 revealed an order for Milk of Magnesia Suspension 30 milliliters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 (ml) once every 24 hours as needed (PRN) for constipation. Level of Harm - Minimal harm or potential for actual harm Review of the Bowel and Bladder Elimination Record for 05/13/24-06/12/24 revealed no documented bowel movements for Resident #23 between 05/15/24 and 06/12/24. Residents Affected - Few Review of the MAR for Resident #23 for the months of May and June 2024 revealed no doses of PRN Milk of Magnesia were administered for constipation. Interview on 06/13/24 at 9:54 A.M. with the DON verified there were no documented bowel movements for Resident #23 on the above dates and the resident did not receive PRN Milk of Magnesia. 3. Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), morbid obesity, major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), hallucinations, osteoporosis, insomnia, intervertebral disc degeneration, spondylosis, spinal stenosis, hypertension (HTN), low back pain, cellulitis of right lower limb, and hyperlipidemia. Review of the MDS assessment dated , 03/27/24, revealed the resident was moderately cognitively impaired. Further review of the MDS data revealed Resident #30 was incontinent of bowel and bladder and dependent for toileting and hygiene. Review of physician orders for Resident #30 revealed an order for Milk of Magnesia Suspension 30 ml once every 24 hours PRN for constipation. Review of the Bowel and Bladder Elimination Record for 05/13/24-06/12/24 revealed no documented bowel movements for Resident #30 on May 15, 17, 18, 19, 20, 21, 23, 27, 29, 30, June 8, 9, and 11. Interview on 06/12/24 at 11:58 A.M. with the DON verified there were no documented bowel movements for Resident #30 on the above dates and the resident did not receive PRN Milk of Magnesia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure recommendations from the audiologist and optometrist were followed. This affected one (Resident #30) of one resident reviewed for vision and/or hearing. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, cognitive communication deficit, morbid obesity, major depressive disorder, anxiety disorder, and hallucinations. Review of the Minimum Data Set (MDS) assessment, dated 03/27/24, revealed the resident was moderately cognitively impaired. Further review of the MDS data revealed Resident #30's vision was adequate with corrective lenses and the hearing was not evaluated. Review of the care plan for Resident #30 revealed the facility will arrange consultation with eye care practitioner as required. Review of the optometry visit dated 10/19/22 revealed the resident complained of blurred vision to both eyes. The resident was identified with a cataract but declined surgery. The resident was identified with no glasses and new glasses were recommended for reading. A follow-up visit was recommended on 10/19/23 for the cataract and new glasses. The medical record did not contain any evidence of any optometry visits in 2023 or 2024. Review of the audiology visit on 10/19/23 revealed the resident presented with complaints of ear pain. The audiologist was unable to establish if there was any hearing loss to bilateral ears The recommendations revealed to consult with the physician for wax removal and re-evaluate the resident's hearing after the wax removal. Interview on 06/10/24 at 8:36 A.M., Director of Social Services (DSS) #474 revealed Resident #30 saw an optometrist on 10/19/22 with recommendations to follow up on 10/19/23. DSS #474 stated Resident #30 has not received follow-up optometry care as recommended. Interview on 06/10/24 at 9:38 A.M., Resident #30 reported having told the facility they have difficulty hearing and would like a hearing aid, but the facility has failed to ensure this occurs. Interview on 06/13/24 at 8:36 A.M. with DSS #474 revealed Resident #30 saw an audiologist on 10/19/23 and received recommendations for follow up care with their medical doctor (MD) for bilateral ear wax removal. Interview on 06/13/24 at 10:11 A.M. with the Director of Nursing (DON) revealed Resident #30 did not receive any MD follow up care or medicine for bilateral ear wax removal in October 2023 as recommended by the audiologist. Review of the facility policy titled Dignity, dated 02/21, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0685 life, and feelings of self-worth and self-esteem. Individual needs and preferences are identified through the assessment process. 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: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 Based on review of the medical record, observation, staff interview, review of manufacturer guidelines, and policy review, the facility failed to ensure a thorough wound assessment was completed and failed to provide appropriate pressure reducing devices. This affected one (#28) of three residents reviewed for pressure ulcers. The facility census was 67. Residents Affected - Few Findings include Review of the medical record revealed Resident #28 had an admission date of 06/09/24. Diagnoses included multiple sclerosis, hypertension, dementia, and a pressure ulcer of the left buttock stage four. Review of the admission physician orders dated 06/09/24 revealed there were no orders for pressure reducing devices Review of the admission assessment completed on 06/09/24 at 5:16 P.M. noted the resident had a stage four pressure ulcer. There were no wound measurements or description of the wound documented. Review of a skin one-time observation tool, dated 06/10/24 at 4:02 P.M., revealed the resident had a stage four pressure ulcer to the left buttock measuring one centimeter (cm) in length by one cm in width by 1.6 cm in depth. There was no description of the wound characteristics or surrounding skin. Observations on 06/11/24 at 7:29 A.M., 8:41 A.M., 11:45 A.M., and 1:36 P.M. revealed Resident #28 was lying on a standard pressure reduction mattress. Interview on 06/11/24 at 8:41 A.M., the Director of Nursing (DON) verified the resident was on a standard pressure reduction mattress. The DON revealed the resident should have a low air loss mattress for a stage four pressure ulcer. Observation on 06/12/24 at 7:41 A.M. revealed Resident #28 was sitting in a recliner and had no pressure reducing cushion in place. Observation on 06/12/24 at 9:46 A.M. revealed Resident #28 remained sitting in a recliner without a pressure relieving cushion in place. Interview on 06/12/24 at 10:15 A.M., Nursing Assistant (NA) #468 verified the resident was sitting in the recliner with no pressure reducing cushion. Interview on 06/12/24 at 10:22 A.M., Rehabilitation Director (RD) #601 verified staff could use the pressure cushion from the resident's wheelchair for the resident's recliner. Observation on 06/12/24 at 10:27 A.M. during wound care with Registered Nurse (RN) #600 and Licensed Practical Nurse (LPN) #414 revealed the resident had a stage four pressure ulcer to the left buttock. The wound was approximately one cm in length by one cm in width with an undetermined depth. There was no wound odor and no drainage. The wound had tunneling of three centimeters at one o'clock. The wound was 100% granulation tissue. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 Level of Harm - Minimal harm or potential for actual harm Interview on 06/12/24 at 2:19 P.M., the DON verified Resident #28 should have a pressure reducing cushion while sitting in her recliner. The DON revealed staff should have obtained an order from the physician for a pressure reducing cushion. The DON also verified there was no documentation in the medical record of a thorough wound assessment for the resident. The DON stated a wound assessment should be completed within 24 hours of admission. Residents Affected - Few Review of manufacturer guidelines for the pressure reduction mattress in use by Resident #28 revealed the mattress may be appropriate for stage one and stage two pressure wounds. Review of the policy titled Skin Assessment, dated 09/14/22, revealed a full body or head to toe skin assessment would be completed upon admission/readmission, daily for three days and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Documentation of the skin assessment includes the skin condition, type of wound, and a description of wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Review of the policy titled Pressure Injury Prevention Guidelines, revised 01/10/23, revealed in the absence of prevention orders, the licensed nurse would utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and notify the physician to obtain orders. Review of the undated policy titled Pressure Injury Prevention Guidelines revealed the standard set cushion for wheelchairs are pressure redistribution seat cushions. Also to provide alternative support surfaces as needed if the resident cannot be positioned off the existing pressure injury or has a stage three, stage four, unstageable, or deep tissue injury on trunk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 - Some 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, staff interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place and chemicals with a precautionary label were secured. This affected two (#23 and #42) of two residents reviewed for accidents. This had the potential to affect three facility-identified independently ambulatory but cognitively impaired residents (#18, #56, and #60) who resided in the building. The facility census was 67 Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/06/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominate side, need for assistance with personal care, abnormal posture, vascular dementia, hypertension. hyperlipidemia, major depressive disorder, and right elbow contracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed [NAME] resident was severely cognitively impaired. Further review of the MDS data revealed Resident #23 was dependent for toileting and requires maximum assistance for showers and bathing and is dependent in all assessed categories for functional status. Review of the plan of care for Resident #23 revealed the resident was at risk for injury related to falls due to gait/balance problems, cerebrovascular accident, and likes to go backwards with wheeled walker. Interventions included a floor mat at bedside. The medical record revealed Resident #23 had a history of falls. Observation on 06/10/24 at 8:47 A.M. revealed resident #23 laying in bed with a blue fall mat leaning against the wall in the room. Interview on 06/10/24 at 8:47 A.M. with State Tested Nursing Assistant (STNA) #467 verified blue fall mat was leaning against the wall in Resident #23's room. STNA #467 revealed the blue fall mat was supposed to be on the floor next to Resident #23's bed as a fall precaution. Interview on 06/12/24 at 9:49 A.M. with Licensed Practical Nurse (LPN) #412 revealed Resident #23 has a history of frequent falls. Review of facility policy titled Falls - Clinical Protocol, dated 03/18, revealed the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. Review of the medical record for Resident #42 revealed an admission date of 02/22/19. Diagnoses included asthma, diabetes mellitus type 2, obesity, disorder of the bone, cervical spinal stenosis, right knee osteoarthritis, hypothyroidism, hypertension, depressive disorder, obstructive sleep apnea, anemia, anxiety, low back pain, right knee pain, and left knee pain. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 Observation on 06/10/24 at 1:26 P.M. revealed a 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach on the windowsill in Resident #42's room. The label on the bottle revealed a warning label which read: Warning: skin and eye irritant. Do not get in eyes or on clothing. Vapors may irritate. For prolonged use, wear gloves. Not for use by persons with heart conditions or chronic respiratory problems. Keep out of reach of children and pets. Residents Affected - Some Observation on 06/11/24 at 8:08 A.M. revealed the 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach remained on the windowsill in Resident #42's room. Interview on 06/11/24 at 8:08 A.M., State Tested Nursing Assistant (STNA) #467 verified the 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach was on the windowsill in Resident #42's room. Review of facility policy titled Storage Areas, Maintenance, revealed cleaning supplies, etc., must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products. The facility identified three (#18, #56, and #60) independently mobile and cognitively impaired residents who resided in the building. This deficiency is non-compliance identified during the investigation of Complaint Number OH00153731. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, and review of facility policy, the facility failed to obtain orders for the use and maintenance of an indwelling urinary catheter and failed to provide proper urinary catheter cleansing. This affected one (#64) of one sampled residents reviewed for indwelling urinary catheters in a facility census of 67. Findings include: Review of the medical record revealed Resident #64 admitted to the facility on [DATE]. Diagnoses included left radius fracture, arthrodesis, type 2 diabetes mellitus, age related osteoporosis with current pathological fracture, chronic kidney disease, anemia, hypertension, neuromuscular dysfunction of bladder, colostomy, and stenosis. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #64 with intact cognition and utilized an indwelling urinary catheter. Review of the care plan dated 12/11/23 addressed Resident #64's indwelling urinary catheter related to neurogenic bladder. Goals included resident will be/remain free from catheter-related trauma and show no signs or symptoms of urinary infection. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door, provide catheter care routinely and as needed (PRN), change as ordered and PRN, and secure catheter securely to thigh to decrease trauma and bladder spasms. Review of physician orders revealed on 02/07/24 the physician ordered catheter care every shift for infection prevention. The record contained no current physician order was contained in the medical record for the placement of an indwelling urinary catheter, the size of urinary catheter to be placed (French (Fr)), or the maintenance of the urinary catheter drainage. Review of the medical record revealed on 02/16/24 a physician evaluation noted the resident to be placed on the antibiotic Macrobid 100 milligrams (mg) twice daily for one week due to tract infection. On 03/14/24 the resident had orders for the antibiotic Keflex Oral Capsule 500 mg by mouth two times a day for seven days for Escherichia Coli and Staphylococcus urinary tract infection. Observation on 06/10/24 at 9:03 A.M. noted Resident #64 with an indwelling catheter in place with associated tubing and drainage bag contained in a privacy bag under the residents wheelchair seat. Interview on 06/10/24 at 9:03 A.M. with Resident #64 at the time revealed she was prone to urinary tract infections. The indwelling catheter has been removed and put into place several times since admission to the facility. The resident reported she was attending an out of facility urology appointment that day to determine potential options related to her urological status. Additional chart review revealed the urology physician evaluation on 06/10/24 noted the resident to request to have her indwelling catheter replaced. The note stated at the facility they were changing her catheter once per week and had upsized her to a 22 French (Fr) due to leakage around the catheter. Recommendations included she go back down to 16 Fr or 18 Fr to avoid urethral erosion which could be a cause of permanent incontinence. Upsizing her catheter will not stop from leaking around (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0690 during bladder spasms. Level of Harm - Minimal harm or potential for actual harm Observation on 06/11/24 at 9:59 A.M. of urinary catheter care with State Tested Nurse Aide (STNA) #408 noted STNA #408 to apply disposable surgical gloves, obtain a basin of water, bottle of shampoo/body wash, wash clothes and towels. STNA #408 proceeded to Resident #64's bedside. STNA #408 exposed Resident #64 perineum, catheter tubing, and verified the tubing was not secured to the residents thigh. STNA #408 then applied body wash to a wet wash cloth, placed the wash cloth to the tubing and wiped toward the insertion point followed by rinsing and drying the resident perineum with the same technique. STNA #408 also wiped the sides of the residents perineum without changing positions of the cloth. At no time did STNA #408 separate the labia to expose the urinary meatus and point of catheter entry. Residents Affected - Few Interview with STNA #408 on 06/11/24 at 10:23 A.M. verified wiping toward the insertion site of the catheter and not changing portions of the wash cloth with wipes. Review of facility policy titled Catheterization of Female, implemented on 04/25/23, noted urinary catheters are to be inserted by licensed nurses under the orders of the attending physician. When determining catheter size, choose the smallest diameter that will provide good drainage (typically 14-16 French (Fr) in adults), unless the resident has blood clots or sediment that may occlude the lumen. Larger catheter sizes and catheter balloon sizes shall not be routinely used, and when used, shall be for the shortest duration as possible. Once inserted, secure the catheter to the resident's thigh. Documentation of the procedure shall include: The type of catheter inserted, including French size and balloon size. Review of the facility policy titled Catheter Care, revised 5-10-2023, identified when providing catheter care to a female steps included the following: Gently separate the labia to expose urinary meatus. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. Dry area with a towel. Interview on 06/12/24 at 11:50 A.M. the Director of Nursing (DON) confirmed there were no current orders to address the placement of the indwelling catheter, size of catheter, or related maintenance of the catheter drainage system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure sliding scale insulin was provided as ordered for one (#34) of six residents reviewed for unnecessary medications. The facility census was 67. Residents Affected - Few Finding include: 1. Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, asthma, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Review the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 received insulin injections seven days during the review period. Resident #34 displayed no behaviors during the review period. Resident #34 required extensive assistance with bed mobility. Resident #34 was dependent on staff for toileting, and parts of dressing. Resident #34 required maximum assistance with bathing. Review of Resident #34's physician orders revealed an order dated 03/28/24, discontinued 05/19/24, and reordered 05/19/24 for Novolog FlexPen subcutaneous solution pen injector 100 unit per milliliter (ml) inject per sliding scale before meals and at bedtime for diabetes mellitus. The sliding scale was as follows: 0-150 = 0, 151-200 = 2, 201-250 = 4, 251-300 = 6, 301-350 = 8, 351-400 =10, 401-450 = 12. Above 450 give max coverage and call physician. Subcutaneously before meals and at bedtime for diabetes mellitus. Review of Resident #34's Medication Administration Record (MAR) for 04/202 revealed on 04/15/24 Resident #34 was administered her 7:00 A.M. sliding scale at 12:28 P.M. and her 11:00 A.M. sliding scale was administered at 12:13 P.M. On 04/24/24 both the 7:00 A.M. and 11:00 A.M. sliding scale doses were administered at 12:12 P.M. All of these entries were completed by Licensed Practical Nurse (LPN) #431. Review of Resident #34's MAR for 05/2024 revealed on 05/01/24 her 7:00 A.M. was administered at 10:09 A.M. On 05/21/24 the 7:00 A.M. sliding scale was administered at 12:12 P.M. and her 11:00 A.M. sliding scale was administered at 12:28 P.M. On 05/22/24 the 7:00 A.M. sliding scale was administered at 11:07 A.M. and her 11:00 A.M. sliding scale was administered at 11:23 A.M. All of these entries were completed by LPN #431. Review of Resident #34's MAR for 06/2024 revealed on 06/06/24 Resident #34's 7:00 A.M. sliding scale was administered at 9:54 A.M. All of these entries were completed by LPN #431. Interview on 06/10/24 at 10:26 A.M. with Resident #34 revealed she was not always getting her blood sugar checks and sliding scale insulin before her meals. Interview on 06/12/24 at 7:41 A.M. with LPN #431 verified she was the nurse who documented Resident #34's sliding scale insulin on 04/15/24, 04/24/24, 05/01/24, 05/21/24, 05/22/24, and 06/06/24. LPN #431 verified Resident #34's 05/01/24 and 06/06/24 were not administered as ordered prior to breakfast. LPN #431 stated she would talk with the Director of Nursing (DON) to see if the actual times of administration could be determined for the other dates. LPN #431 reported the times documented in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the MAR were not the actual time of administration. She stated she inadvertently did not correct the time of administration when there were log in issues. Interview on 06/12/24 at 11:05 A.M. with the DON revealed there was no additional documentation regarding Resident #34's sliding scale insulin. The DON verified Resident #34's insulin was documented as not being administered as ordered on 04/15/24, 04/24/24, 05/01/24, 05/21/24, 05/22/24, and 06/06/24. Review of the facility policy titled Timely Administration of Insulin, revised 05/04/22, revealed it was the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of the manufacturer instructions, the facility failed to ensure resident medications were properly labeled and expired medications were not available for use past the expiration date. This affected two medication rooms (C-Hall and B-Hall) and one medication cart (C-Hall). The facility census was 67. Findings include: Observation of the C-Hall medication storage room on 06/12/24 at 8:01 A.M. with the Director of Nursing (DON), revealed two expired blister cards of benzonate 100 milligram (mg) capsules. The first blister card contained three benzonate 100 mg capsules and was marked with an expiration date of 03/28/23. The second blister card contained twenty-nine benzonate 100 mg capsules and was marked with an expiration date of 05/12/24. Further observation of the C-Hall medication storage room revealed ipratropium 0.03% nasal solution with an expiration date of 02/28/23. Interview with the DON at the time of observation verified both blister cards of benzonate and the ipratropium 0.03% nasal solution were expired. Observation of the C-Hall medication cart on 06/12/24 at 8:20 A.M. with Licensed Practical Nurse (LPN) #431, revealed a 10 milliliter (ml) vial of Lantus insulin glargine injection 100 units/ml, that was approximately one-half full, marked with an open date of 05/08/24. There was also one bottle of folic acid 1 mg tablets, containing approximately 75 tablets which was open with no date they were opened identified and no expiration date on the bottle. Review of the manufacturer's instructions for Lantus insulin glargine injection revealed to discard the insulin 28 days after opening. Interview with LPN #431 at the time of observation verified the manufacturer instructions on the vial of Lantus insulin glargine stated it was to be used within 28 days of opening. Interview with the DON on 06/12/24 at 8:20 A.M., verified the bottle of folic acid 1 mg tablets was open, not marked with a date they were opened, and had no expiration date. Observation of the B-Hall medication storage room on 06/12/24 at 8:33 A.M., with the DON revealed one bottle of folic acid 1 mg tablets, containing approximately 75 tables, was open with no date they were opened and no expiration date. Interview with the DON at the time of observation verified the bottle of folic acid 1 mg tablets was open, not marked with a date they were opened, and had no expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered laboratory (lab) testing was completed as indicated. This affected one resident (#35) of five residents reviewed for unnecessary medications. The facility census was 67. Residents Affected - Few Findings Include: Review of Resident #35's medical record revealed an admission date of 02/09/18. Diagnoses included dementia, type II diabetes, major depressive disorder, psychosis, seizures, anxiety disorder, and insomnia. Review of Resident #35's physician orders revealed an order dated 10/12/21 for divalproex sodium (Depakote) tablet delayed release 250 milligrams (mg). Give 1 tablet by mouth two times a day related to seizures. An order dated 08/22/22 instructed to obtain valproic acid levels every six months due to Depakote drug therapy starting on 22nd. Review of Resident #35's laboratory (lab) results found no lab results for Resident #35's valproic acid levels. Review of Resident #35's 05/10/24 psychiatric note revealed Resident #35's labs were reviewed. There was no indication Resident #35 had valproic acid level lab completed. Interview on 06/13/24 at 8:48 A.M. with the Director of Nursing (DON) verified he had contacted the lab and Resident #35 had not had any valproic labs completed. Review of the facility policy titled Lab and Diagnostic Test Results - Clinical Protocol, revised November 2018, revealed the physician would identify and order diagnostic and lab testing based on the residents diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and facility policy review, the facility failed to provide dental services to meet the residents needs. This affected one resident (#30) of one resident reviewed for dental. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, morbid obesity, major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), hallucinations, osteoporosis, insomnia, intervertebral disc degeneration, spondylosis, spinal stenosis, hypertension (HTN), low back pain, cellulitis of right lower limb, and hyperlipidemia. Review of the Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the care plan for Resident #30 revealed they are at risk for oral/dental health problems related to many missing teeth. The facility will coordinate arrangements for dental care, transportation as needed/as ordered. The record had no evidence of Resident #30 seeing a dentist. Interview on 06/10/24 at 9:37 A.M. with Resident #30 revealed they have an upper denture, but it does not fit. Their bottom jaw has multiple missing teeth, with a sharp tooth that catches their tongue. They have told the facility they would like dentures, but their request has not been acted upon. Interview on 06/13/24 at 8:36 A.M. with Director of Social Services #474 revealed Resident #30 has not seen a dentist since their admission. Review of the facility policy titled Ability of Services, Dental, dated 08/07, revealed dental services are available to all residents requiring routine and emergency dental care. Social Services will be responsible for making necessary dental appointments. Inquiries concerning the availability of dental services should be referred to Social Services or to the Director of Nursing. Residents with lost or damaged dentures will be promptly referred to a dentist. Review of the facility policy titled Dental Examination/Assessment, dated 12/13, revealed each resident shall undergo a dental assessment prior to or within ninety (90) days of admission. Residents shall be offered dental services as needed. Records of dental care provided shall be made a part of the resident's medical record. Review of the facility policy titled Dental Consultant, dated 04/07, revealed the facility does not maintain a resident dentist on staff. A consultant dentist is retained by our facility and is responsible for providing a dental assessment of each resident within ninety (90) days of admission and performing or supervising an annual dental reevaluation for each resident. Review of the facility policy titled Dental Service, dated 12/16, revealed it is the facilities policy that routine and emergency dental services are available to meet the resident's oral health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0791 services in accordance with the resident's assessment and plan of care. 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: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure food provided to residents was palatable and attractive. This had the potential to affect all residents in the facility. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating. Review of Resident #39's care plan, revised 01/29/24, revealed supports and interventions for nutritional risk. Interview on 06/10/24 at 9:29 A.M. with Resident #39 reported her bacon was undercooked this morning and her food items were often not cooked well enough and cold. Observation on 06/10/24 at 12:34 P.M. of Resident #39's lunch tray found her to have been provided pizza with cheese on the top that appeared unmelted. Coinciding interview with Resident #39 verified the meal she was provided was unappetizing, cold, the cheese was not melted and the personal pizza appeared to be under cooked. Observation on 06/11/24 at 8:21 A.M. found Resident #39 had been provided her breakfast meal. Coinciding interview with Resident #39 revealed she was unhappy with her breakfast sausage which she stated was cold and undercooked. Resident #39 reported she was not going to eat it because it was grey, spongy, and unappetizing. Resident #39 held up the sausage pointed to one of the sausages ends and stated when the sausage was properly cooked it would be brown like the small area on the end. Resident #34 stated the grey soggy meat was undercooked. Interview on 06/11/24 at 8:24 A.M. with State Tested Nursing Assistant (STNA) #463 verified Resident #39's sausage was grey soggy, undercooked, and unappetizing. Interview on 06/11/24 at 9:03 A.M. with STNA #408 revealed the meat provided from the kitchen was often not cooked well. STNA #408 reported she had brought the residents concerns to the kitchen but for the last few days it has continued to be undercooked. Interview on 06/11/24 at 9:04 A.M. with Dietary Manager (DM) #479 revealed the breakfast sausage came precooked and was heated to 165 degrees before being served. DM #479 broke open Resident #39's uneaten breakfast sausage and showed the meat was grey all the way through. DM #479 verified the meat was grey and stated if it had been raw it would have been pink. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 observation, staff interview, and policy review, the facility failed to ensure meals were served in a sanitary manner. This affected four residents (#50, #54, #19, #11) and had the potential to affect all residents who were receiving meals from the kitchen. The facility census was 67. Findings include Observation on 06/11/24 at 11:35 A.M., of meal plating revealed [NAME] #446 was wearing gloves and directly touched the hamburger buns, lettuce, and tomatoes then touched the plates, counter, scoop handles, tongs and bag containing hamburger buns. The cook then again directly touched the hamburger buns, lettuce, and tomato with the same gloved hands. [NAME] #446 repeated this process four times while plating meals for four residents (#50, #54, #19, #11). After surveyor intervention, [NAME] #446 changed his gloves but completed no hand washing, then used tongs for the hamburger buns, lettuce, and tomato. Interview on 06/11/14 at 11:35 A.M., [NAME] #446 verified he was touching the serving handles, plates, and counter then touching the food directly with the same gloved hands. [NAME] #446 verified he had not washed his hands in between glove changes. Interview on 06/11/14 at 11:44 A.M., Dietary Manager (DM) #479 verified staff should wash their hands when changing gloves. Interview on 06/12/24 at 2:35 P.M., the Director of Nursing (DON) verified all residents received meals from the kitchen. Review of the undated policy titled Hand Washing, revealed employees shall wash their hands and exposed portions of their arms after handling soiled equipment or utensils, following contact with any unsanitary surfaces, before putting on disposable gloves at the beginning of a task or when changing tasks, before distributing trays/meals to residents. Disposable gloves shall not be substituted for proper hand washing. Review of the undated policy titled Disposable Gloves, revealed disposable gloves shall be worn when working with any food to avoid contact with bare hands. Suitable utensils, single use disposable gloves, deli tissues, tongs, or dispensing equipment shall be used to prevent cross-contamination. Disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruption occur in operation. Hand washing shall occur prior to putting on gloves and whenever gloves were changed (if the task has changed) or removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility medical records, staff interview, and review of facility policies, the facility failed to ensure residents received influenza and pneumococcal immunizations. This affected two (#13 and #43) of five residents reviewed for influenza and pneumococcal immunizations in a facility with a census of 67. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the pneumococcal immunization to be administered. Review of the medical record revealed no documentation the pneumococcal immunization was ever administered to Resident #13. Resident #13 was documented as refusing the pneumococcal immunization. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained verbal consent for the pneumococcal immunization for Resident #13 on 11/29/23, but the immunization was not administered to the resident. The ADON also verified Resident #13 had consented to receive the pneumococcal immunization but it was documented in the medical record as refused. 2. Review of the medical record for Resident #43 revealed an admission date of 12/01/22. Diagnoses included convulsions, protein-calorie malnutrition, anxiety disorder, insomnia, sarcopenia, gastro-esophageal reflux disease, anorexia, and gastrostomy status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. Review of facility immunization consent records revealed the facility obtained a signed consent from Resident #43 on 10/27/23 for the pneumococcal immunization, but there was no documentation of the immunization being administered. Review of Resident #43's Medication Administration Record (MAR) for November 2023 revealed no documentation that pneumococcal immunization was administered. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained written consent for the pneumococcal immunization for Resident #43 on 10/27/23 but the immunization was not administered to the resident. Review of the facility policy titled Pneumococcal Vaccine (Series), dated 03/02/23, revealed each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0883 Level of Harm - Minimal harm or potential for actual harm immunization may be administered in accordance with physician-approved standing-orders. A pneumococcal vaccination is recommended for all adults aged 65 years and older. A pneumococcal vaccination is recommended for adults 19-[AGE] years old who have certain chronic medication or other risk factors. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility medical records, staff interview, and review of the facility policy, the facility failed to ensure residents received COVID-19 immunizations. This affected one (Resident #13) of five residents reviewed for COVID-19 immunizations in a facility with a census of 67. Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the COVID-19 immunization, but there was no documentation of the immunization being administered. Review of Resident #13's physician orders identified an order dated 12/11/23 for COVID-19 mRNA (Moderna) Intramuscular Suspension (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine). Review of the medical record for December 2023 revealed the immunization was never administered to Resident #13. Resident #13 was documented as refusing immunization. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained verbal consent for the COVID-19 immunization for Resident #13 on 11/29/23, an order was placed for COVID-19 mRNA (Moderna) Intramuscular Suspension (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine) on 12/121/23, but the immunization was not administered to the resident, and the COVID-19 immunization was documented as refused in the resident's medical record. Review of facility policy titled COVID-19 Vaccination, dated 02/14/22, revealed it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complication from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, review of maintenance repair records, and review of facility policy, the facility failed to ensure all portions of resident call devices were functioning properly. This affected one resident (#58) of eight residents reviewed on the C Hall. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #58's medical record revealed an admission date of 02/01/23. Diagnoses included heart failure, cirrhosis of the liver, severe protein calories malnutrition, edema, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was moderately cognitively impaired. Resident #58 was dependent on staff for toilet use, bathing, and transfer. Resident #58 required moderate assistance with personal hygiene. Review of Resident #58's care plan revised 03/14/24 revealed supports and interventions for self-care deficit, risk for pain, risk for falls, and bowel and bladder incontinence. Interview on 06/10/24 at 9:54 A.M. with Resident #58 reported her call light had not been functioning properly for the last eight months and no one had been able to fix it. Resident #58 reported repairs were made on a couple occasions but the call light functioned properly for only a couple days and it was broken again. Resident #58 reported it did not light up in her room or in the hallway. Resident #58 activated her call light and it was observed the light in the hallway and the light on the call light panel next to her bed did not light up. Resident #58 stated maintenance was aware of the issue and gave her a stick with bells on it. Resident #58 stated she was also told the indicator light at the nurses station was still functioning when her call light was activated. Resident #58 stated the partially functioning call light was a safety issue because staff working the hallways were not always able to hear the small bells or know the call light was activated because they were often providing care to others and not in range of the nurses station. Interview on 06/10/24 at 9:57 A.M. with the Director of Nursing (DON) verified Resident #58's light above her door was not functioning but her light did register at the nurses station. Interview on 06/11/24 at 4:14 P.M. with Maintenance Director (MD) #457 verified the facility was aware of Resident #58's call light not functioning properly and the light in the hallway did not activate when Resident #58 pushed her call button. MD #457 reported they had some service work done to it and were waiting on a part to have it repaired again. Review of the services work orders for Resident #58's call light revealed a repair was completed 10/31/23. On 02/16/24 a quote for a full call system upgrade was received from a local communication company. On 03/27/24 a component for the call system at the nurses station for Resident #58's room was replaced and Resident #58's call light was functioning at the time. No other repairs were found. Interview on 06/12/24 at 9:38 A.M. with MD #457 revealed the call light issue for Resident #58 began in October of 2023 and was repaired. On 03/27/24 there again was an issue with the call light and a component for the call system at the nurses station for Resident #58's room was replaced and the call light was functioning. On 02/16/24 a quote was received from a local communications company for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365907 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 365907 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Franciscan Care Ctr Sylvania 4111 Holland Sylvania Rd Toledo, OH 43623 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete an upgrade of the call light system. MD #457 reported the quote was sent to corporate and had not yet been approved. Maintenance Director #457 verified Resident #58's call light did not currently function in her room or in the hallway, however, it did signal at the nurses station when Resident #58 pressed her call light. Review of the facility policy titled Maintenance Service, revised December 2009, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operational manner at all times. Event ID: Facility ID: 365907 If continuation sheet Page 32 of 32