Inspection·September 7, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy titled Quality of Life, Dignity, dated 08/09 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. 2. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, insomnia, constipation, right below the knee amputation, hypertension, deep vein thrombosis (blood clot) and congestive heart failure. Review of a facility Inventory of Personal Effects form, dated 01/20/21 revealed Resident #65 was admitted with one shirt, one coat, one pair of shoes, one sweat suit/warm up suit and one heating pad. This resident was admitted with no other personal effects. Review of the quarterly MDS 3.0 assessment, dated 08/12/21 revealed Resident #65 had a BIMS score of 15 which reflected intact cognition. The assessment revealed the resident required extensive assistance from one to two staff members for bed mobility, transfers, toileting and dressing. Review of the personal fund account held by the facility for Resident #65 revealed the account held a balance of $2,027.63 on 09/02/21 and did not contain any purchases of clothing since the residents admission to the facility. On 08/30/21 at 4:22 P.M. Resident #65 was observed in bed wearing a hospital gown and incontinence brief. On 08/31/21 at 10:50 A.M. Resident #65 was observed in bed wearing a hospital gown and incontinence brief. The closet and drawers in the resident's room were absent of any articles of clothing. One pair of shoes was observed sitting on the floor next to the resident's closet. On 08/31/21 at 10:50 A.M. Resident #65 was asked about clothing and his preferences for dressing. The resident indicated he would rather have personal clothing to wear instead of the hospital gown but stated he did not have anything to wear. Resident #65 denied facility staff asking about or purchasing any articles of clothing for him since he had been admitted to the facility. On 09/02/21 at 9:28 A.M. Resident #65 was observed in bed with only a hospital gown and incontinence brief on. Interview with Activity Director (AD) #200 on 09/02/21 at 1:00 P.M. revealed Resident #65 had arrived to the facility with only the clothing he had on and had not had any additional clothing purchased for him by the facility. AD #200 revealed she was not aware of the resident's preference for dressing or that the resident needed/wanted more clothing to wear at the facility. AD #200 revealed she had not spoken with the resident personally and relied on State Tested Nursing Assistant (STNA) staff at the facility to write down any personal belongings a resident requested or needed. Review of the facility policy titled Quality of Life, Dignity, dated 08/09 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 2 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to ensure Resident #9's family/responsible party was notified of falls sustained by the resident and failed to ensure Resident #32's family/responsible party was notified of weight loss. This affected two residents (#9 and #32) of 19 sampled residents. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the resident's monthly physician's orders for September 2021 revealed an order, dated 05/09/21 for a broda chair as needed for positioning and an order dated 06/11/21 for a pressure sensor alarm to the resident's bed and chair with the special instructions to check function and placement every shift and as needed. Review of a fall investigation revealed Resident #9 sustained a fall from bed on 05/08/21 at 6:00 P.M. with no evidence the resident's family was notified of the fall. Review of a fall investigation revealed Resident #9 sustained a fall from bed on 05/10/21 at 2:00 P.M. with no evidence the resident's family was notified of the fall. On 09/01/21 at 1:54 P.M. interview with Registered Nurse (RN) #99 verified the facility had no evidence of Resident #9's family being notified of the above falls. Review of the facility policy titled Change in a Resident's Condition or Status, dated 12/2016 revealed the facility shall promptly notify the resident's attending physician and representative of changes in the resident's medical and/or mental condition. 2. Review of Resident #32's medical record revealed an original admission date of 03/31/15 with the latest readmission of 03/26/21. Resident #32 had diagnoses including dementia, anxiety disorder, dysphagia, diabetes mellitus, insomnia, gastrostomy, encephalopathy, constipation, mood disorder, major depressive disorder, chronic pain, urine retention, psychosis and hypertension. Review of the nutritional review, dated 07/05/21 revealed the resident's weight was 167.4 pounds and the resident had a 4.1% weight decrease in the past 30 days, 5% weight loss in the past 90 days and 2.4% weight loss in the past 180 days. Further review revealed no documented evidence the resident's family was notified of the resident's weight loss. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 3 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had unclear speech, rarely/never understood others, rarely/never made himself understood and had a severe cognitive deficit. Review of the resident's monthly physician's orders for September 2021 revealed orders for enteral feeding, Glucerna 1.5 at 70 milliliters (ml)/hour continuously per gastric tube with 250 ml (water) flush every four hours and a regular oral pureed diet with thin liquids. On 09/02/21 at 10:20 A.M. interview with the Director of Nursing (DON) verified the family was not notified of Resident #32's weight loss. Review of the facility policy titled Change in a Resident's Condition or Status, dated 12/2016 revealed the facility shall promptly notify the resident's attending physician and representative of changes in the resident's medical and/or mental condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 4 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive care plans were developed for all residents. The facility failed to develop a plan of care for Resident #9 related to dental/oral needs, for Resident #32 related to insomnia and for Resident #31 related to anticoagulant medication use. This affected three residents (#9, #31 and #32) of 19 sampled residents who care plans were reviewed. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's admission assessment dated [DATE] revealed the resident had his own teeth with no carried or broken teeth. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed the resident was dependent on one staff for personal hygiene and had obvious or likely cavity or broken natural teeth. Review of the resident's plan of care revealed the resident had no plan of care related to oral/dental care needs, likely cavity/carried or broken natural teeth. On 08/30/21 at 10:35 A.M. Resident #9 was observed to have carried teeth. On 09/01/21 at 3:17 P.M. interview with Registered Nurse (RN) #2000 verified the resident had no care plan addressing oral/dental care needs, likely cavity/carried or broken natural teeth. 2. Review of Resident #32's medical record revealed an original admission date of 03/31/15 with the latest readmission of 03/26/21. Resident #32 had diagnoses including dementia, anxiety disorder, dysphagia, diabetes mellitus, insomnia, gastrostomy, encephalopathy, constipation, mood disorder, major depressive disorder, chronic pain, urine retention, psychosis and hypertension. Review of the resident's quarterly MDS 3.0 assessment, dated 08/20/21 revealed the resident had unclear speech, rarely/never understood others, rarely/never made himself understood and had a severe cognitive deficit. The assessment indicated the resident received antidepressant medications. Review of the resident's monthly physician's orders for September 2021 revealed an order, initiated 03/26/21 for Trazadone 50 milligrams (mg) by mouth daily at bedtime for insomnia. Review of the resident's plan of care revealed no care plan addressing the resident's use of an antidepressant medication to treat insomnia had been developed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 5 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 On 09/02/21 at 10:39 A.M. interview with RN #201 verified the resident had no plan of care for the use of Trazadone to treat insomnia. 3. Review of the medical record for Resident #31 revealed an admission date of 07/31/20 with diagnoses including schizophrenia, vascular dementia with behavioral disturbance, chronic viral hepatitis C, dysphagia and hypertension. Review of the quarterly MDS 3.0 assessment, dated 07/09/21 revealed Resident #31 was severely cognitively impaired and had received an anticoagulant medication for seven days during the look back period. Review of the plan of care, dated 07/15/21 revealed the resident had the potential for alteration in perfusion related to hypertension. Interventions included monitoring for signs and symptoms of bleeding every shift and as needed. Review of the physician's order, dated 02/23/21 revealed an order for Eliquis 2.5 milligrams (mg) twice a day for six months related to a diagnosis of deep vein thrombosis. On 09/02/21 at 8:02 A.M. and 8:05 A.M. interview with the Director of Clinical Services (DCS) confirmed Resident #31's care plan did address the reason for monitoring the resident for signs and symptoms of bleeding. The DCS confirmed the care plan did not address the resident's history of deep vein thrombosis or use of an anticoagulant. Review of the policy titled Anticoagulant policy, revised September 2012 revealed facility staff and physician were to monitor for possible complications in individuals on anticoagulants. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 6 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 Based on observation, record review and interview the facility failed to ensure Resident #3, #15 and #52, who required staff assistance with activities of daily living (ADLs) received timely and adequate assistance with meals to promote proper nutrition. This affected three residents (#3, #15 and #52) of four residents reviewed for ADL care/nutrition. The facility identified all 69 residents residing in the facility required assistance with meals. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date of 03/27/14 with diagnoses including unspecified dementia with behavioral disturbance, dysphagia, unspecified open-angle glaucoma, schizophrenia and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/01/21 revealed Resident #3 had impaired cognition and was totally dependent on one staff member for eating. Review of the plan of care, dated 08/02/21 revealed Resident #3 had an activity of living (ADL) self care performance deficit related to limited range of motion, refusal of care, refusal to participate, confusion, and diagnoses including schizophrenia, dementia, pain, and anxiety. Interventions included providing necessary level of assistance with ADLs and indicated the resident was dependent on staff for bathing, grooming, eating and locomotion. Observation on 08/30/21 of the lunch meal revealed the meal trays arrived on the 600 hall at 11:50 A.M. and the trays were distributed to all residents on the unit. Resident #3, who resided on the unit, was observed laying in bed with his meal tray on his bedside table next to his nightstand until State Tested Nursing Assistant (STNA) #53 entered the room to feed him at 12:33 P.M. On 08/30/21 from 12:37 P.M. to 12:43 P.M. interview with STNA #53 confirmed Resident #3 received assistance 43 minutes after the meals arrived. She reported the times the residents who needed assistance ate varied because they had several residents on the unit who required assistance with meals. STNA #53 revealed Resident #3 was able to feed himself at times, but only if he was handed the dishes. STNA #53 revealed Resident #3, had days like this day where he was unable to feed himself. STNA #53 revealed staff would reheat food if it were necessary. She stated she looks for steam or holds her hand over the food to determine the temperature. 2. Review of the medical record for Resident #52 revealed an admission date of 02/21/17 with diagnoses including unspecified dementia with behavioral disturbance, hypertension, contractures of the right hip, right knee, and left hip, dysphagia, schizophrenia and adult failure to thrive. Review of the quarterly MDS 3.0 assessment, dated 07/28/21 revealed Resident #52 was rarely or never understood and totally dependent on staff for eating. Review of the plan of care, dated 08/03/21 revealed Resident #52 had an ADL self care performance deficit related to limited range of motion, diagnoses including dementia, contractures of left hand, right and left elbow, hypertension and anxiety. Interventions included providing necessary level of assistance with ADLs and indicated the resident was dependent on staff for bathing, dressing, grooming, bed mobility, eating, transfers and locomotion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 7 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 Residents Affected - Few Observation on 08/30/21 of the lunch meal revealed the meal trays arrived on the 600 hall at 11:50 A.M. and the trays were distributed to all residents on the unit. Resident #52 was observed lying in bed with his meal tray on a bedside table next to his nightstand until Helping Hand #30 (a hospitality aide) began feeding him at 12:40 P.M. On 08/30/21 from 12:37 P.M. to 12:43 P.M. interview with STNA #53 confirmed Resident #52 received assistance 50 minutes after the trays arrived on the hall. 3. Review of the medical record for Resident #15 revealed an admission date of 06/13/12 with diagnoses of unspecified dementia with behavioral disturbances, schizophrenia, contracture of left hand, right hand, left knee, left hip, right knee, and right hip, depression, dysphagia and extrapyramidal and movement disorder. Review of the quarterly MDS 3.0 assessment, dated 07/05/21 revealed Resident #15 had impaired cognition and was totally dependent on one staff person for eating. Review of the plan of care, dated 07/27/21 revealed Resident #15 had an ADL self-care performance deficit related to limited range of motion, limited mobility, musculoskeletal impairment, confusion, refusal to participate at times, refusal of care at times and diagnoses including dementia and contractures. Interventions included providing necessary level of assistance with ADLs and indicated the resident was dependent on staff for bathing, dressing, grooming, bed mobility, eating, transfers and locomotion. Observation on 08/30/21 of the lunch meal revealed the meal trays arrived on the 600 hall at 11:50 A.M. and the trays were distributed to all residents on the unit. Resident #15 was observed lying in her bed with her meal on the bedside table night to her night stand until Assistant Director of Clinical Services (ADCS) #99 arrived to feed her at 12:44 P.M. At 12:59 P.M. Helping Hand #30 came in to take over feeding Resident #15. Interview with Helping Hand #30 at the time of the observation confirmed the lateness of the meal for Resident #15. Review of the policy titled Resident Nutrition Services, dated July 2017 revealed residents were to receive prompt meal service and appropriate feeding assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 8 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #59 revealed an admission date of 11/02/16 with diagnoses including schizophrenia and chronic obstructive pulmonary disease. Residents Affected - Few Review of the MDS 3.0 assessment, dated 08/06/21 revealed the resident had moderate cognitive impairment with a Brief Interview for Mental Status score of 10. On 08/30/21 at 12:01 P.M. and 08/31/21 at 3:06 P.M. Resident #59 was observed to have a band-aid on his left thumb. Interview with Resident #59 on 08/31/21 at 3:06 P.M. revealed he burned his thumb while smoking. Interview with Licensed Practical Nurse (LPN) #999 on 09/01/21 at 2:20 P.M. revealed Resident #59 had a burn on his thumb from a cigarette. She stated he smokes his cigarettes down to the end and refuses to use any adaptive smoking equipment. She stated the burn was noticed a couple days ago. She stated a treatment was being completed to the burn daily. Observations, at that time, revealed LPN #999 removed the band-aid from Resident #59's thumb. The resident was observed with a dime sized red area with the top layer of skin gone from the back of his thumb. LPN #999 cleaned his thumb, applied Bacitracin with zinc ointment, and applied a new band-aid. Review of the medical record revealed no documentation regarding the burn on the thumb. There was no evidence the physician was notified, no evidence of a physician's order for a treatment to the thumb, no documentation of any treatment being done to the thumb, and no evidence of a non-pressure skin condition form being initiated to monitor the condition of the burn. Review of the facility policy titled Care of Skin Tears, Abrasions and Minor Breaks revealed the purpose of the procedure was to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. The policy revealed to obtain a physician's order as needed and document physician notification in the medical record. Generate a non pressure form and complete. The policy revealed an abrasion was an area on the skin that had been damaged by friction, scraping, rubbing or trauma. The policy indicated to complete an in-house investigation of causation, how the resident tolerated the procedure, any complications and interventions implemented to prevent additional abrasions. Interview with the Director of Nursing on 09/02/21 at 8:00 A.M. confirmed non pressure skin conditions were to be monitored on a non pressure skin condition record when identified and weekly. Interview with LPN #999 on 09/01/21 at 2:20 P.M. confirmed there was no documentation related to the burn on Resident #59's thumb. She confirmed there was no evidence the physician was notified, a treatment was ordered, or a skin condition form was initiated to assess and monitor the burn. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure treatment for a non-pressure related skin impairment was completed as ordered by the physician for Resident #65 and failed to appropriately assess and treat a cigarette burn on Resident #59's thumb following the injury. Actual harm occurred on 06/16/21 when Resident #65 was admitted to the hospital and diagnosed with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the second left toe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 9 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 had to have the second left toe amputated. Treatment for non-pressure related skin impairment to the toe area was not completed as ordered after 05/13/21. Level of Harm - Actual harm Residents Affected - Few This affected two residents (#59 and #65) of three residents reviewed for hospitalization and/or skin conditions. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Review of the facility Non-Pressure Skin Condition Record, dated 04/28/21 revealed a skin tear to the left second toe of Resident #65 measured 3.0 centimeters (cm) long by 2.0 cm wide by 0.1 cm deep. On 05/03/21 the area was documented to measure 3.3 cm wide by 2.5 cm long, by 0.3 cm deep. Review of a physician order, dated 05/03/21 revealed an order was obtained at that time to cleanse the second toe to the left foot with soap and water, pat dry, apply calcium alginate and apply a clean, dry dressing. The order for the dressing was to be completed every other day and as needed until resolved. Review of the Treatment Administration Records (TARs) for 05/2021 and 06/2021 revealed physician ordered treatments were documented as being completed to the area on the left second toe until 05/13/21 when the treatment was discontinued on the TAR and documentation on the TAR identified the area had resolved. Continued review of the assessment records revealed on 05/31/21 the area to the left second toe measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. On 06/07/21 the area measured 4.8 cm long, by 2.2 cm wide, by 0.2 cm deep. Weekly Skin Integrity reviews for Resident #65, dated 04/28/21, 05/05/21, 05/12/21, 05/19/21, 05/26/21, 06/02/21 and 06/09/21 revealed the resident was documented to have a skin tear to the second left toe during each assessment. There was no evidence after 05/13/21 staff had identified the lack of treatment order or need for treatment to the area. Review of a podiatry visit note, dated 06/16/21 revealed Resident #65 was seen due to a large, infected wound to his left second toe which contained necrotic tissue and had bone visible. An order was obtained on 06/16/21 to send Resident #65 to the emergency room (ER) for further evaluation. Review of hospital documentation, dated 06/16/21 through 06/18/21 revealed Resident #65 was admitted to the hospital with diagnoses including osteomyelitis of the second left toe resulting in the second left toe being amputated. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility. Review of the care plan, revised on 08/25/21 revealed Resident #65 had the potential for altered skin integrity related to diagnoses including diabetes mellitus, depression and chronic obstructive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 10 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 pulmonary disorder (COPD). Interventions included weekly skin checks, follow physician order for preventive treatment and Braden scale quarterly. Level of Harm - Actual harm Residents Affected - Few On 09/01/21 at 1:55 P.M. interview with the Director of Nursing (DON) verified the physician ordered treatment for Resident #65's wound to the left second toe had not been completed after 05/13/21 as staff had incorrectly documented on the TAR the area was resolved. The DON verified weekly skin assessments and weekly wound measurements showed the wound remained to the second toe from 04/28/21 through 06/16/21 when the resident was sent to the hospital and his second left toe was amputated. On 09/01/21 at 2:30 P.M. Resident #65 was observed with a small scabbed area to the second left toe which had been amputated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 11 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on observation, record review and interview the facility failed to provide intervention/adaptive equipment as ordered for Resident #15 and Resident #52 who were assessed to have limitation in range of motion. This affected two residents (#15 and #52) of two residents reviewed for range of motion. Findings Include: 1. Review of the medical record for Resident #52 revealed an admission date of 02/21/17 with diagnoses including unspecified dementia with behavioral disturbance, hypertension, contractures of the right hip, right knee, and left hip, dysphagia, schizophrenia and adult failure to thrive. Review of the physical therapy and occupational therapy functional maintenance program, dated 01/06/20 revealed the resident was to have a hip abductor pillow daily from 8:00 A.M. to 2:00 P.M. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/28/21 revealed Resident #52 was rarely or never understood, totally dependent on staff for bed mobility, transfers, dressing, eating, toilet use and personal hygiene and had limited range of motion in his upper and lower extremities on both sides. Review of the August 2021 physician's orders revealed orders for a right resting hand splint up to eight hours during the day to be removed at bedtime, a left elbow positioner/extender daily as tolerated for up to eight hours to be removed at night and left palm guard to be worn while in bed. Review of the physician's order, dated 08/17/21 revealed an order to discontinue the right resting hand splint and left elbow positioner extender and to begin a right elbow positioner/extender and left palm guard daily up to eight hours as tolerated. Review of the August 2021 Treatment Administration Record (TAR) revealed the left palm guard, the right resting hand splint, and the left elbow positioner/extender were marked as provided from 08/01/21 to 08/31/21 at 3:00 PM. Further review revealed written on the TARs was the resident was to utilize hip abductor pillow during the day as tolerated, this was listed as For your Information (FYI), there was no start date and no documentation to indicate this had been completed. Additionally, it was documented Resident #52 was to utilize a left palm guard during the day as tolerated, as an FYI, there was no start date and there was no documentation to indicate this had been provided as ordered. Review of an occupational therapy discharge note, dated 08/26/21 revealed a recommendation to begin right elbow extension splint and right hand palm guard. On 08/30/21 at 10:40 A.M., from 12:00 P.M. to 12:40 P.M., at 1:19 P.M., and between 4:20 P.M. and 4:30 P.M. observation of Resident #52 revealed he was not wearing any adaptive equipment on his arms or hands. Review of the TAR on 08/30/21 at 4:20 P.M. revealed a right resting hand splint was documented as being put on in the morning, a left elbow positioner/extender was documented as having been put on in the morning, and a left palm guard was documented as having been completed for the period of 7:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 12 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0688 A.M. to 3:00 A.M. for 08/30/21. Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Practical Nurse (LPN) #58 from 4:20 P.M. to 4:30 P.M. confirmed she had marked the equipment as being in place on 08/30/21. Observation of Resident #52 with LPN #58 at that time, revealed he was not wearing any adaptive equipment on his arms or hands. This observation was confirmed by LPN #58. LPN #58 revealed Resident #52 may have gotten a shower earlier and the equipment was not put back on. LPN #58 stated she had gotten busy that morning and had not checked to make sure the devices were in place as ordered. Residents Affected - Few On 09/01/21 at 8:50 A.M. interview with Physical Therapist #622 and Occupational Therapist #621 revealed Resident #52's should have been using a hip abductor pillow, left hand palm guard and right arm extender. Occupational Therapist #621 revealed Resident #52 should no longer be wearing his left extender and right hand splint; the discharge note was an error in listing the right hand palm guard. On 09/01/21 at 4:24 P.M. interview with Registered Nurse (RN) #2000 confirmed the left elbow positioner and right resting hand splint continued past the date to discontinue. RN #2000 confirmed there was nothing in place to monitor when the left palm guard or hip abductor were in use. She additionally confirmed there was no documentation in the TAR related to the right elbow positioner/extender. 2. Review of the medical record for Resident #15 revealed an admission date of 06/13/12 with diagnoses of unspecified dementia with behavioral disturbances, schizophrenia, contracture of left hand, right hand, left knee, left hip, right knee, and right hip, depression, dysphagia and extrapyramidal and movement disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/05/21 revealed Resident #15 had impaired cognition and was totally dependent on one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The assessment revealed the resident had limited range of motion in both sides of her upper and lower extremities. Review of the plan of care, dated 07/27/21 revealed Resident #15 was a candidate for restorative programs related to the need for various amounts of staff assistance with activities of daily living. Interventions included left hand palm guard and right hand protector. Review of the signed physician's orders revealed an order, dated 07/12/21 for the resident to utilize a left hand palm shield and right hand palm guard up to eight hours daily. On 08/30/21 at 10:40 A.M., from 12:00 P.M. to 12:59 P.M., at 1:19 P.M. and between 4:20 P.M. and 4:30 P.M. observation of Resident #15 revealed she was not wearing any adaptive equipment on her hands. Review of the TAR for 08/30/21 at 4:20 P.M. revealed the use of the palm guard to left hand was documented as having been completed for the period of 7:00 A.M. to 3:00 A.M. Interview with LPN #58 from 4:20 P.M. to 4:30 P.M. confirmed she had marked the equipment as being in place on 08/30/21. Observation of Resident #15 with LPN #58 at that time, revealed the resident was not wearing any adaptive equipment on the arms or hands. This observation was confirmed by LPN #58. LPN #58 stated she had gotten busy that morning and had not checked to make sure the devices were in place as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 13 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, staff interview and facility policy review the facility failed to fall/safety interventions were in place as ordered for Resident #9. This affected one resident (#9) of three residents reviewed for falls. Findings Include: Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the fall evaluation, dated 05/07/21 revealed a score of 20 indicating Resident #9 was at a high risk for falls. Review of the plan of care, dated 05/20/21 revealed the resident was at risk for injury related to poor safety awareness, confusion, incontinence, history of falls, diabetes mellitus, dementia, hypertension and chronic obstructive pulmonary disease. Interventions included investigate each fall to determine root cause, maintain a clear pathway free of obstacles, ensure the resident's call light was within reach and encourage the resident to use the call light, educate the resident/family/caregivers about safety reminders, medication review as needed, administer medication as ordered, encourage to participate in activities, keep needed items in reach, anticipate and meet the resident's needs, observe for any changes in physical, emotional, cognitive or visual status and report to physician, assess for injuries when placing self onto the floor, redirect/distract when placing self onto the floor, pressure sensor to bed and chair as prevention and to alert staff to resident's attempt to ambulate. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/21 revealed the resident had unclear speech, usually understood others, usually made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the mood and behavior section of the MDS revealed the resident had hallucinations, delusions, displayed verbal and physical behaviors towards other and behaviors not directed towards others. The resident was dependent on one staff for bed mobility and transfers and was non-ambulatory. Review of the monthly physician's orders for September 2021 revealed an order, dated 06/11/21 for a pressure sensor alarm to bed an chair with the special instructions to check function and placement every shift and as needed. On 09/01/21 at 12:06 P.M. Resident #9 was observed sitting in a geriatric chair being fed his lunch by State Tested Nursing Assistant (STNA) #888. At the time of the observation, no pressure sensor alarm was observed to be in place under the resident. Interview with STNA #888 at the time of the observation revealed the STNA had never seen the resident have a sensor alarm in his bed or chair and verified the pressure sensor alarm was not in place at that time. Review of the facility policy titled Managing Falls and Fall Risk, dated 12/2007 revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 14 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 complications from falling. 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: 365932 If continuation sheet Page 15 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide nutritional interventions, including timely and adequate assistance with meals to Resident #65 to prevent weight loss. Residents Affected - Few Actual harm occurred when Resident #65, who was dependent on staff for eating and assessed to sustain a 20.9% severe weight loss in 180 days (on 02/12/21 the resident weighed 240.6 pounds and on 08/10/21 the resident weighed 190.2 pounds loss of 50.4 pounds in 180 days) did not receive adequate or timely assistance with meals on 08/30/21 and 09/01/21. This affected one resident (#65) of four residents reviewed for weight loss. Findings include: Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Resident #65's weight on admission [DATE]) was documented to be 254 pounds. Review of Resident #65's meal intake records revealed in January 2021 staff documented the resident was consuming 75% to 100% of meals. Continued meal intake records from February 2021 through April 2021 revealed the resident's intakes had decreased. On 03/26/21 the resident was assessed to weigh 230 pounds. The next recorded weight, on 04/07/21 was 210 pounds. This reflected a 20 pound weight loss in 12 days. There was no evidence a re-weight was obtained at that time. In April 2021 the dietitian recommended nutritional shakes twice a day which were documented as being provided as ordered. Review of the care plan, dated 05/14/21, revealed Resident #65 was at risk for imbalanced nutrition related to diuretic use, diabetes mellitus, hypertension and COPD. Interventions included to monitor for signs or symptoms of dysphagia such as pocketing or holding food in mouth, dental consult as needed and assist with feeding as needed. Review of the meal intake records from June through August 2021 continued to reflect the resident had decreased intake for meals. There was no evidence the facility re-assessed to cause of the decreased intakes at this time or implemented new interventions to increase meal intake or prevent additional weight loss. Review of the facility Vital Sign and Weight Record from 02/12/21 through 08/10/21 revealed Resident #65 experienced a 20.9% severe weight loss in 180 days. On 02/12/21 Resident #65's weight was 240.6 pounds (lbs). On 08/10/21, Resident #65's weight was 190.2 lbs, a loss of 50.4 lbs in the past 180 days. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. The MDS revealed the resident had a significant weight loss of over 10% in six months and was not on a prescribed weight loss regimen. Review of the dietary progress notes, dated 08/12/21 revealed the weight history for Resident #65 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 16 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0692 Level of Harm - Actual harm showed a significant weight loss over 180 days and a moderate weight loss over 90 days. The weight loss over 180 days had been contributed to a large fluid loss and decline in the residents status. There was no evidence of any new nutritional interventions being considered or implemented at this time. In addition, record review revealed no evidence the resident was prescribed diuretic medication. Residents Affected - Few Review of the corresponding nursing progress notes from 01/13/21 to 08/30/21 revealed no evidence Resident #65 had any type of edema noted. Observations of the resident throughout the annual survey, from 08/30/21 through 09/01/21 revealed no signs of edema noted. In addition, there were no notes related to diuretic use. On 08/30/21 at 12:30 P.M. observation of the lunch meal revealed meal trays arrived to the unit on the dining cart at this time. Observation on 08/30/21 at 12:38 P.M. revealed State Tested Nursing Assistant (STNA) #777 placed the lunch tray for Resident #65 on his bedside table and placed the table over the resident. STNA #444 opened the containers and cut up the chicken Parmesan on the resident's plate and walked out of the room. Observation on 08/30/21 at 12:56 P.M. revealed Resident #65 was leaning to his left side in the bed attempting to use his fork to pick up pieces of chicken but was unable to and was pushing the food off his plate onto his tray. No staff members were observed in the room while the resident was attempting to consume his lunch meal. Observation on 08/30/21 at 1:06 P.M. revealed Resident #65 was slumped to his left side in the bed with his lunch meal in front of him on the bedside table and had consumed less than 10% of his lunch meal. Multiple gnats were observed to have landed on the resident's lunch meal. Resident #65 was rolling a substance around in his mouth and spit out a piece of unchewed chicken Parmesan which was covered in saliva onto his tray. Interview with Registered Nurse (RN) #99 and Licensed Practical Nurse (LPN) #58 on 08/30/21 at 1:06 P.M. verified gnats had landed on Resident #65's lunch meal, the resident was slumped over to his left side, and the did not appear to be able to chew the chicken Parmesan on his lunch tray or feed himself his lunch meal. RN #99 revealed she would get an order to downgrade Resident #65's diet from regular texture to a dysphagia advanced diet. Observation on 08/30/21 at 1:10 P.M. revealed LPN #58 began cutting the food on Resident #65's tray into smaller pieces and was observed to feed the resident his lunch meal. Interview with STNA #777 on 08/30/21 at 1:20 P.M. revealed staff did not provide assistance with meals to Resident #65 as he was able to feed himself after his meal was set-up. Observation on 09/01/21 at 12:12 P.M. revealed STNA #959 removed the lunch meal tray for Resident #65 from the dining cart, took it into his room, removed the lid from his plate, and set it on his tray table which was located next to his bed out of his reach as he was lying in bed with the head of his bed not raised. STNA #959 exited the room without opening the container of milk or removing the lids from the container of ice cream of cup of coffee. Observation on 09/01/21 at 12:30 P.M. revealed Resident #65 continued to lie in bed with the head of his bed not raised. The lunch meal for Resident #65 continued to remain on the tray table next to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 17 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0692 his bed which was not within his reach. Gnats were observed to be landing on the residents meat loaf, mashed potatoes, and peas. Level of Harm - Actual harm Residents Affected - Few Interview with Resident #65 on 09/01/21 at 12:30 P.M. revealed the resident stated he was hungry, wanted to eat and thought he could sit up by himself to be able to eat his lunch meal but was unable to do so. Attempts to obtain additional information from the resident regarding assistance with meals/feeding could not be obtained as the resident was noted to have some cognitive impairment and could only answer simple questions and would not engage in conversation with the surveyor. Observation on 09/01/21 at 12:42 P.M. revealed STNA #959 walked back into the room of Resident #65 and attempted to sit him up on the side of the bed but was unable to. STNA #959 raised the head of the resident's bed instead and positioned the tray table containing his lunch meal across him, did not open his container of milk or remove the lids from his coffee and ice cream, and then exited the room. Resident #65 was observed to ask where his milk was after STNA #959 exited the room, but no staff members were around to hear his question. Interview with Resident #65 on 09/01/21 at 12:47 P.M. revealed he was unsure where his container of milk was at and stated staff normally opened it and handed it to him. Observation on 09/01/21 at 12:52 P.M. revealed Resident #65 was picking peas up one at a time with his fingers and was putting them into his mouth. Observation on 09/01/21 at 12:54 P.M. revealed STNA #959 entered Resident #65's room, asked the resident if his food was good, moved the container of milk to the edge of the resident's tray but did not open it, then exited the residents room. Observation on 09/01/21 at 12:56 P.M. revealed Resident #65 picked up his straw from his tray, removed the wrapper, and was attempting to place the straw into the unopened container of milk. Interview with RN #5000 on 09/01/21 at 1:05 P.M. verified only a few peas and one bite of mashed potatoes had been eaten by Resident #65, gnats were flying around the residents food, and the cup of coffee and container of ice cream remained unopened on the residents tray. Interview on 09/01/21 at 2:55 P.M. with Registered Dietician (RD) #1000 revealed she was aware of the weight loss experienced by Resident #65. Dietician #1000 verified the Resident #65 continued to have gradual weight loss every week since being admitted to the facility and was unsure as to why the resident's weight continued to decline. As a result of the interview, there was no evidence the dietician had considered the weight loss a result of the resident requiring and not receiving adequate assistance from staff with meal intake. Resident #65 had a current plan of care intervention to assist with feeding as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 18 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, record review and staff interview the facility failed to ensure Resident #32's enteral feeding was labeled with the solution, date and time the enteral feeding was initiated/started to prevent the risk of complication(s) from the enteral feeding. This affected one resident (#32) of one resident reviewed for enteral feeding. Findings Include: Review of Resident #32's medical record revealed an original admission date of 03/31/15 with the latest readmission of 03/26/21. Resident #32 had diagnoses including dementia, anxiety disorder, dysphagia, diabetes mellitus, insomnia, gastrostomy, encephalopathy, constipation, mood disorder, major depressive disorder, chronic pain, urine retention, psychosis and hypertension. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/20/21 revealed the resident had unclear speech, rarely/never understood others, rarely/never made himself understood and had a severe cognitive deficit. The resident was dependent on one staff for eating. The resident was coded as having no known weight loss, received abdominal feeding tube and received a mechanically altered diet. The resident received 51% or more of his calories a day from the tube feeding and 501 milliliters (ml)/day or more of fluids from the tube feeding. Review of the resident's monthly physician's orders for September 2021 revealed orders for Glucerna 1.5 at 70 ml/hour continuously per gastric tube with 250 ml (water) flush every four hours and a regular oral pureed diet with thin liquids. On 08/30/21 at 10:39 A.M. observation of the resident's enteral feeding revealed there was no label identifying the solution or date and time when the solution was initiated/started. On 08/30/21 at 12:15 P.M. interview with Licensed Practical Nurse (LPN) #888 verified the enteral feeding had no label identifying the solution or date and time when the solution was initiated/started. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 19 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (#9 and #32) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of a pharmacy recommendation, dated 05/28/21 revealed the pharmacist recommended to add a Vitamin B12 supplement. The physician agreed with the recommendation but did not date when the review was completed. Review of the physician's orders revealed a telephone order, dated 07/02/21 for Vitamin B12 1000 units by mouth daily. On 09/01/21 at 10:34 A.M. interview with Registered Nurse (RN) #2001 verified the physician had not addressed the pharmacy recommendation in a timely manner. An order was not obtained until 07/02/21 when the pharmacy recommendation was made on 05/28/21. 2. Review of Resident #32's medical record revealed an original admission date of 03/31/15 with the latest readmission of 03/26/21. Resident #32 had diagnoses including dementia, anxiety disorder, dysphagia, diabetes mellitus, insomnia, gastrostomy, encephalopathy, constipation, mood disorder, major depressive disorder, chronic pain, urine retention, psychosis and hypertension. Review of a pharmacist recommendation, dated 10/29/20 revealed the recommendation for a gradual dose reduction (GDR) of the resident's Trazadone 25 milligrams (mg) daily at bedtime. The physician failed to address the recommendation until 12/03/20. On 09/02/21 at 10:06 A.M. interview with the Director of Nursing (DON) verified the pharmacy recommendation was not addressed by the physician in a timely manner. The recommendation was made on 10/29/20 and not addressed until 12/03/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 20 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Residents Affected - Few Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech, usually understood others, usually made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the resident's monthly physician's orders for September 2021 revealed an order for weekly blood pressures (BP) on Sunday related to medication being administered for hypertension. Review of the resident's medical record failed to provide documented evidence the resident's BP was being obtained every Sunday. On 09/01/21 at 2:37 P.M. interview with Registered Nurse (RN) #2000 verified the resident's BP had not been taken every Sunday as physician ordered to ensure medication for hypertension was effective and administered at optimal dose. 3. Review of Resident #43's medical record revealed an admission date of 02/11/19 with the admitting diagnoses of hypertension, hyperlipidemia, Alzheimer's disease, dementia, psychotic disorder, diabetes mellitus type II, insomnia, depression and unspecified psychosis. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had unclear speech and had significant cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of three. Review of the resident's monthly physician's orders for September 2021 revealed in April 2021, a recommendation was made by the pharmacist to decrease Aspirin 325 mg daily to 81 mg daily as higher doses would increase the risk of bleeding. Physician agreement was received and signed the same month. However, review of physician's orders revealed the resident had been receiving Aspirin 325 mg daily since it was originally written on 12/14/20 and had not been changed per pharmacy recommendation. Interview with Registered Nurse (RN) #2000 on 09/02/21 at 11:22 A.M. verified a recommendation to decrease Aspirin 325 mg by mouth daily to Aspirin 81 mg by mouth daily in April 2021 was received by the facility. The RN verified the physician acknowledged and agreed with the recommendation the same month (April 2021). However, the recommendation was never transcribed to the resident's orders and the resident continued to receive the Aspirin 325 mg daily as it was written on 12/14/2020. Based on observation, record review and interview the facility failed to monitor residents for side effects of medication, prevent unnecessary medications and follow pharmacy recommendations when Resident #31 received an anticoagulant past the prescribed end date and was not monitored for side effects related to the medication, Resident #9's blood pressure was not obtained as ordered to monitor an antihypertensive medication and Resident #43's Aspirin dose was not changed following a pharmacy recommendation. This affected three residents (#31, #9 and #43) of five residents reviewed for unnecessary medication use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 21 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Findings Include: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident #31's medical record revealed an admission date of 07/31/20 with diagnoses including schizophrenia, vascular dementia with behavioral disturbance, chronic viral hepatitis C, dysphagia and hypertension. Residents Affected - Few Review of the physician's orders revealed an order, dated 02/23/21 for Eliquis 2.5 milligrams (mg) twice a day for six months for a diagnosis of deep vein thrombosis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed Resident #31 was severely cognitively impaired and had received an anticoagulant for seven days during the look back period. Review of the plan of care, dated 07/15/21 revealed Resident #31 had the potential for alteration in perfusion related to hypertension. Interventions included monitoring for signs and symptoms of bleeding every shift and as needed. Review of the Medication Administration Record (MAR) for August 2021 revealed Eliquis 2.5 mg twice a day was written in. The MAR revealed the order was continued past 08/23/21, and was given twice daily on 08/24/21, 08/25/21, 08/26/21, 08/27/21, 08/28/21, 08/29/21, 08/30/21 and 08/31/21. The medication should have been discontinued on 08/23/21 (six months after the order was initiated on 02/23/21). Review of Resident #31's medical record revealed there was no evidence the resident was being monitored for bleeding and bruising. On 08/31/21 at 3:08 P.M. interview with Licensed Practical Nurse (LPN) #899 revealed Resident #31 was currently on Eliquis. On 08/31/21 at 3:10 P.M. interview with LPN #56 revealed she had given Resident #31 Eliquis that morning at 6:00 A.M. On 09/01/21 at 2:25 P.M. and on 09/02/21 at 8:02 A.M. interview with the Director of Clinical Services (DCS) confirmed Resident #31's Eliquis went over the prescribed time period, and there was no extension to the original order. She additionally indicated she was unable to find evidence the facility was monitoring the resident for side effects of the medication. The DCS confirmed Resident #31 had a care planned intervention to monitor for signs and symptoms of bleeding every shift and as needed. Review of the policy titled Anticoagulant policy, revised September 2012 revealed facility staff and physician were to monitor for possible complications for individuals on anticoagulants. Additional review revealed the physician would identify individuals whose anticoagulant could be discontinued or reduced and would document a rationale for continuing anticoagulation over time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 22 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's medical record revealed an admission date of 05/07/21 with the admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Residents Affected - Few Review of the resident's admission assessment, dated 05/07/21 revealed the resident had his own teeth with no carried or broken teeth. Review of the resident's comprehensive MDS 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. The resident was dependent on one staff for personal hygiene. The assessment indicated the resident had obvious or likely cavity or broken natural teeth. Review of the resident's plan of care revealed the resident had no plan of care related to the likely cavity or broken natural teeth. Review of the resident's medical record failed to provide any documented evidence the resident had seen or had been offered to be seen by a dentist since admission to the facility. On 08/30/21 at 10:35 A.M. observation of Resident #9 revealed the resident had obvious carries to his teeth. On 09/01/21 at 1:22 P.M. interview with Medical Records #400 verified the resident had not seen a dentist since being admitted to the facility. Based on observation, record review and interview the facility failed to ensure timely dental services were provided for Resident #9 and Resident #65. Actual harm occurred on 09/02/21 when Resident #65, who had been referred for tooth extraction (on 04/27/21) was assessed to have an infected tooth which required antibiotic treatment. The facility failed to ensure a follow up appointment for the extraction was completed timely after the need for the extraction was identified on 04/27/21 resulting in the resident developing an infection. This affected two residents (#9 and #65) of the three residents reviewed for dental services. Findings Include: 1. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Review of a physician order, dated 04/20/21 revealed Resident #65 was ordered the antibiotic Clindamycin 150 milligrams (mg) four times a day for 10 days due to an oral abscess. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 23 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 Level of Harm - Actual harm Residents Affected - Few A dental visit progress note, dated 04/27/21 revealed Resident #65 was seen at the facility by the dentist and was recommended to have his one remaining tooth extracted. A referral was left with the facility to send the resident out to have the tooth extracted. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/12/21 revealed Resident #65 was assessed to require extensive assistance from one staff member for bed mobility and set-up assistance and supervision for meals. Review of a physician's order, dated 09/02/21 revealed Resident #65 was prescribed the antibiotic, Amoxicillin 500 mg by mouth three times a day for seven days due to a tooth infection. Interview with the Director of Nursing (DON) on 09/01/21 at 4:00 P.M. verified Resident #65 had been seen by the dentist on 04/27/21 and the dentist had recommended Resident #65 be sent to another dental facility to have his one remaining tooth extracted. The DON was unable to provide evidence the referral had been made or evidence of any follow-up regarding the needed appointment. The DON verified Resident #65 had not been seen by a dentist since 04/27/21 and no follow-up appointment had been scheduled. Interview with Licensed Practical Nurse (LPN) #999 on 09/02/21 at 1:30 P.M. revealed Resident #65 was seen at the facility by the Nurse Practitioner (NP) on this date and the NP had been prescribed antibiotics due the resident's tooth being infected. This was the tooth the dentist had recommended being extracted on 04/27/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 24 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, record review and interview the facility failed to ensure the correct diet that met resident needs was provided when whole broccoli florets were given to residents on a dysphagia advanced diet instead of chopped broccoli. This had the potential to affect 18 residents (#5, #8, #14, #16, #17, #28, #33, #37, #38, #39, #44, #45, #48, #54, #58, #60, #63 and #268) of 18 residents identified to have orders for a dysphagia advanced diet. The facility census was 69. Findings Include: On 08/31/21 from 11:25 A.M. to 12:10 P.M. observation of the lunch meal service revealed two available vegetable options puree broccoli and regular broccoli florets. Further observation revealed 14 residents, Resident #5, #8, #14, #16, #17, #33, #39, #45, #48, #54, #58, #60, #63 and #268 on a dysphagia advanced diet were served regular broccoli florets. Review of the Diet Guide Sheet for lunch on Tuesday 08/31/21, day 10 of Week two of the menu cycle, revealed residents on the dysphagia advanced diet were to receive chopped broccoli florets. On 08/31/21 at 12:27 P.M. interview with Healthcare Services Group District Manager (HSDM) #236 confirmed residents on the dysphagia advanced diet were given regular broccoli florets when the diet guide called for chopped broccoli florets. HSDM #236 revealed the kitchen staff usually served chopped broccoli. On 08/31/21 at 3:42 P.M. interview with Dietary Manager (DM) #69 also confirmed residents on the dysphagia advanced diet were given the same full broccoli florets as those on the regular diet. DM #69 revealed the broccoli usually came in smaller pieces and not whole florets, so normally both diets would get the same broccoli. DM #69 revealed the cook had not considered the change in the broccoli Review of the resident list with diets revealed 18 residents, Resident #5, #8, #14, #16, #17, #28, #33, #37, #38, #39, #44, #45, #48, #54, #58, #60, #63 and #268 were ordered a dysphagia advanced diet. Review of the undated diet terminology conversion sheet revealed a dysphagia advanced diet was to be soft or ground, a dysphagia level 3 diet called for chopped, fine chopped and mechanical soft food items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 25 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview the facility failed to ensure resident refrigerators were maintained at appropriate temperatures and were clean and free from expired food items. This affected four residents (#2, #20, #26, and #28) who resided on the 400 unit and had refrigerators in their rooms. The facility census was 69. Findings Include: 1. Observation on 09/01/21 at 8:30 A.M. of the refrigerator in Resident #28's room revealed the shelves had a sticky substance adhered to them and the refrigerator did not have a thermometer inside it. Review of a refrigerator temperature log located on the side of the refrigerator was dated 07/2021 and contained documentation only for 07/28/21 which stated No thermometer. Interview with Licensed Practical Nurse (LPN) #999 on 09/01/21 at 8:30 A.M. verified the refrigerator shelves contained a sticky substance and needed cleaned, the refrigerator did not contain a thermometer, and the refrigerator temperature log was dated 07/2021 and had only been filled out on 07/28/21 stating No thermometer. 2. Observation on 09/01/21 at 8:33 A.M. of the refrigerator in Resident #20's room revealed the refrigerator temperature log, dated 07/2021, located on the side of the refrigerator only contained a documented temperature for 07/27/21. The refrigerator shelves contained a sticky substance, a quarter loaf of bread with a Best If Used By date of 07/22/21 and an opened carton of milk with an expiration date of 08/20/21. Interview with LPN #999 on 09/01/21 at 8:33 A.M. verified the refrigerator shelves contained a sticky substance and needed cleaned, the refrigerator temperature log was dated 07/2021 and had only been filled out on 07/27/21, and the loaf of bread and carton of milk in the refrigerator were past their expiration and Best If Used By dates. 3. Observation on 09/01/21 at 8:35 A.M. of the refrigerator in Resident #26's room revealed a refrigerator temperature log dated 07/2021 did not contain any recorded temperatures, there was not a thermometer located inside the refrigerator, and there was a container of opened cream cheese spread which contained an expiration date of 03/27/21. Interview with LPN #999 on 09/01/21 at 8:33 A.M. verified the refrigerator temperature log was dated 07/2021 and did not contain any recorded temperatures, there was no thermometer inside the refrigerator, and there was an open container of cream cheese spread which contained an expiration date of 03/27/21 which should have been thrown out months ago. 4. Observation on 09/01/21 at 8:36 A.M. of the refrigerator in Resident #2's room revealed a refrigerator temperature log dated 07/2021 did not contain any recorded temperatures and there was not a thermometer inside the refrigerator. Interview with LPN #999 on 09/01/21 at 8:36 A.M. verified the refrigerator temperature log was dated 07/2021 and did not contain any recorded temperatures and there was not a thermometer located inside the refrigerator. LPN #999 stated the night shift State Tested Nursing Assistants (STNA's) were responsible for cleaning and recording temperatures in residents refrigerators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 26 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's comprehensive MDS 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. Review of the resident's monthly physician's orders for September 2021 identified orders dated 05/09/21 for a broda chair as needed for positioning, 06/11/21 for a pressure sensor alarm to the resident's bed and chair with the special instructions to check function and placement every shift and as needed. Fall investigations, dated 05/08/21 at 6:00 P.M. and 05/10/21 at 2:00 P.M. revealed Resident #9 sustained falls from bed on these dates. Review of the resident's medical record revealed no evidence these falls were included in the resident's medical record/progress notes. On 09/01/21 at 1:09 P.M. interview with the Director of Nursing (DON) verified the resident's falls occurring on 05/08/21 and 05/10/21 were not documented in the resident's medical record. 4. Record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, anxiety, depression, insomnia, constipation, right below the knee amputation, deep vein thrombosis (DVT) and congestive heart failure (CHF). Review of admission and discharge records for Resident #65 revealed the resident was discharged from the facility on 02/25/21 and did not return to the facility until 03/08/21. However, review of the facility Vital Sign and Weight Record revealed Resident #65 had a documented weight of 239.2 pounds on 02/28/21, a documented weight of 235.8 on 03/04/21, a documented blood pressure of 128/72 on 03/04/21, a documented pulse of 80 beats per minute on 03/04/21, a documented respiratory rate of 20 breaths per minute on 03/04/21 and a documented temperature of 98.1 on 03/04/21. Interview with the Director of Nursing (DON) on 09/01/21 at 4:44 P.M. verified Resident #65 was not present in the facility from 02/25/21 through 03/08/21. The DON revealed she had entered the weight and vital signs for Resident #65 on 02/28/21 and 03/04/21. The DON indicated the weight documented on 02/28/21 had actually been obtained prior to Resident #65 being discharged on 02/25/21 but the day she entered it into the resident's medical record was 02/28/21. The DON revealed she had no explanation for the weight and vital signs documented on 03/04/21 as Resident #65 had not yet returned to the facility. The DON revealed the State Tested Nursing Assistant staff obtain the weights and vital signs for residents and gave them to the her and then she enters them in the facility Vital Sign and Weight Record for the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 27 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0842 Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure resident medical records were maintained in a complete and accurate manner. This affected four residents (#9, #15, #31 and #65) of 19 sampled residents whose medical records were reviewed. Findings Include: Residents Affected - Some 1. Review of the medical record for Resident #15 revealed an admission date of 06/13/12 with diagnoses including unspecified dementia with behavioral disturbances, schizophrenia, contracture of left hand, right hand, left knee, left hip, right knee, and right hip, depression, dysphagia and extrapyramidal and movement disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition and was totally dependent on one staff for bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Review of the physician's orders for August 2021 revealed orders for Medpass 2.0, 90 cubic centimeters (cc's) four times a day, Mighty Shakes four times a day with meals, magic cup with lunch and dinner, Senna 8.6 milligrams (mg) two tablets at bedtime for constipation and Ibuprofen 100 milligrams (mg) per 5 milliliters (ml) by mouth twice daily at 9:00 A.M. and 9:00 P.M. On 08/31/21 at 5:00 P.M. review of the Medication Administration Record (MAR) for Resident #15 revealed for 08/31/21 the Mighty Shake at bedtime was signed as administered with 100% intake, Medpass 2.0 90 cc at 9:00 P.M. was signed as administered with 100% intake and the Magic Cup at 5:00 P.M. was signed as administered with 100% intake. Additional review revealed both the Ibuprofen and Senna that were to be administered on 08/31/21 at 9:00 P.M. were already signed as being administered. Interview with Registered Nurse (RN) #2000 on 08/31/21 at 5:11 P.M. confirmed the Mighty Shake and Medpass were signed as being administered early on this date. RN #2000 revealed the documentation of administration was completed by the morning nurse, who probably signed off at the wrong time. RN #2000 then confirmed it was different initials than the medications earlier in the day. RN #2000 then indicated they had a new person who probably signed the administration in error. On 08/31/21 at 5:14 P.M. Activities Aide (AA) #95 was observed feeding Resident #15. AA #95 revealed the nurse had not been down to see the resident during dinner. Additional interview with RN #2000 at 5:17 P.M. confirmed the 5:00 P.M. Magic Cup had already been signed as administered by the nurse with 100% consumption although the nurse had not observed this to be completed. On 08/31/21 at 5:23 P.M. interview with the Director of Clinical Services (DCS) confirmed the 9:00 P.M. Senna and Ibuprofen had already been documented as being administered which was too early. The DSC was unsure why the medications were signed early, however, she did state the supplements were documented in error when the nurse was giving the supplement intake to another staff member to document. Additional interview with the DCS at 5:36 P.M. revealed the Ibuprofen and Senna had not been given, she stated someone got a little signature happy. On 08/31/21 at 5:49 P.M. interview with Licensed Practical Nurse (LPN) #56 revealed she had been Resident #15's nurse on this date. LPN #56 revealed she was telling Assistant Director of Clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 28 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0842 Level of Harm - Minimal harm or potential for actual harm Services (ADCS) #99 the supplement intake totals for the day and she must have put them in the wrong spot. She was unable to explain why all the supplement spots for 08/31/21 were filled in with just the supplement intakes for the day shift. LPN #56 was unable to explain why the medications were signed off early. She additionally said ADCS #99 must have gotten signature happy and added you guys make us nervous. Residents Affected - Some Review of the facility policy titled Administering Medications, dated December 2012 revealed the individual administering the medication must initial the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next one. 2. Review of the medical record for Resident #31 revealed an admission date of 07/31/20 with diagnoses including schizophrenia, vascular dementia with behavioral disturbance, chronic viral hepatitis C, dysphagia and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed Resident #31 was severely cognitively impaired. Review of the July 2021 physician's orders revealed an order for Juven twice a day. However, written over this was discontinue. There was no date to indicate when this was discontinued. Review of the nutritional review dated 07/13/21 revealed the dietitian recommended Juven to be discontinued. Review of the nutritional recommendation, dated 07/13/21 revealed a recommendation to discontinue Juven. All nutrition recommendations were marked as completed on 07/16/21. Review of the July 2021 MAR revealed Juven was administered twice a day from 07/01/21 through 07/14/21 and was then marked as discontinued. Review of the August 2021 physician's orders and MAR revealed no evidence the Juven was administered. On 09/01/21 at 9:45 A.M. interview with ADCS #99 revealed she was unable to provide evidence the physician had been notified of the dietitian's recommendation or signed an actual order to discontinue the Juven. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 29 of 30 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 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/07/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor of Lucasville II 10098a Bear Creek Road Lucasville, OH 45648 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 and interview the facility failed to maintain an effective pest control program to prevent the presence of gnats/flies in the resident environment. This affected two residents (#9 and #65) of 19 sampled residents. Residents Affected - Few Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. On 08/30/21 at 10:35 A.M. observation of Resident #9 revealed he had a fly crawling on his forehead. The resident asked for someone to remove the fly stating he was unable to remove the fly from his head. On 08/30/21 at 3:15 P.M. observation revealed Resident #9 was complaining about a fly. State Tested Nursing Assistant (STNA) #30 told the resident she would would look for a fly swatter. The STNA walked to the charting room where she was observed to ask the nurse for a fly swatter. No fly swatter was available. On 08/30/21 at 3:28 P.M., Resident #9 was observed yelling for help to remove flies. One fly was observed on the resident's arm. The resident said STNA #30 had not returned with a fly swatter. STNA #30 was down the hallway and confirmed she hadn't found a fly swatter but said she had managed to kill one fly. On 08/30/21 at 3:58 P.M. STNA #30 was observed in Resident #9's room room with a fly swatter killing the fly swarming resident's head. The STNA verified the resident had flies in his room and stated she was unable to remove the flies when landing on him. 2. On 08/30/21 at 1:06 P.M. observation of the lunch meal revealed multiple gnats were observed to have landed on Resident #65's meal. Interview with Registered Nurse (RN) #99 and Licensed Practical Nurse (LPN) #58 on 08/30/21 at 1:06 P.M. verified multiple gnats had landed on Resident #65's lunch meal Observation on 09/01/21 at 12:30 P.M. revealed multiple gnats were observed landing on the lunch meal of Resident #65. Interview with RN #5000 on 09/01/21 at 1:05 P.M. verified multiple gnats were flying around and landing on Resident #65 and the resident's meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 30 of 30