Inspection·August 17, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify one resident's (#218) physician of a change in condition. This affected one (Resident #218) of four residents reviewed for accidents. The census was 64. Findings Include: Review of the medical record for Resident #218 revealed an initial admission date of 04/20/16 with the latest readmission of 07/13/23 with diagnoses including paranoid schizophrenia, chronic obstructive pulmonary disease, repeated falls, difficulty in walking, unsteadiness on feet, generalized muscle weakness, extrapyramidal and movement disorder, bipolar II disorder, anxiety disorder, legal blindness , atrial fibrillation, ocular manifestations of vitamin A deficiency, disorder of urea cycle metabolism, dizziness and giddiness, benign prostatic hyperplasia, dysphagia, bullous keratopathy right eye, open angle glaucoma both eyes, acquired absence of eye, hyperlipidemia, constipation, speech disturbances, history of falling, pain, manic episodes, gastro-esophageal reflux disease, dry eye syndrome, obstructive and reflux uropathy, functional dyspepsia, hypertension, retention of urine, allergic rhinitis and psychosis. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had delusions. The resident required extensive assistance of one staff with bed mobility, transfers and ambulation. The assessment indicated the resident was occasionally incontinent of both bowel and bladder. The assessment indicated the resident had no falls since prior assessment completion. Review of the plan of care dated 03/03/23 revealed the resident was at risk for falls related to confusion, gait/balance problems, unaware of safety needs, vision/hearing problems, history of fall, difficulty walking, muscle weakness and lack of coordination. Interventions included anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident's environment is safe at all times, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, floor mat at bedsides, follow facility fall protocol, left side assist bar to bed to serve as enabler, perimeter mattress to bed, therapy to evaluation and treat if indicated status post fall. Review of the resident's progress note dated 11/12/22 at 7:46 A.M. revealed the resident had complained to staff members early this morning about his left ankle was hurting. When observing left ankle, the ankle appeared swollen, little discoloration, compared to right ankle. The resident reported he did not remember how or when his ankle started bothering him. The resident was also observed lying on the floor after breakfast because he was unable to walk on left ankle. The resident stated he had been getting on the floor because he was unable to stand on foot. Review of the resident's progress note dated 11/12/22 at 10:22 A.M. revealed the resident was found on the floor at 10:00 A.M. lying on his left side with head against the bedroom door. The resident was noted to not have his shoes on properly. The resident stated he was okay and did not fall and hit the floor but tried to crawl because his ankle was hurting. The resident was assisted to bed. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 FORM CMS-2567 (02/99) Previous Versions Obsolete resident's physician was then notified of the resident's inability to bear weight on the resident's left ankle as well as the pain. New orders were given to obtain an X-ray of the left ankle. On 08/17/23 at 12:30 P.M., interview with the Director of Clinical Services (DCS) verified the nurse should have notified the resident's physician of the resident's inability to bear weight on the left ankle due to pain when first discovered. Event ID: Facility ID: 365932 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure one resident (#55) was free from physical restraints. This affected one (Resident #55) of three residents reviewed for restraints. The facility census was 64. Residents Affected - Few Findings Include Review of the medical record for Resident #55 revealed an initial admission date of 04/07/22 with the latest readmission of 05/13/23 with diagnoses including sepsis, anterior displaced type II dens fracture with delayed healing, chronic viral hepatitis, insomnia, tobacco use, Alzheimer's disease, generalized muscle weakness, shortness of breath, difficulty in walking, unsteadiness, dysphagia, dementia with behavioral disturbances, disorders of bladder, neurogenic bladder, hypertension and atrial fibrillation. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the mood and behavior revealed the resident had both hallucinations and delusions. The assessment indicated the resident required extensive assistance of one for bed mobility, transfers and ambulation. The assessment indicated the resident had and indwelling urinary catheter and was frequently incontinent of bowel. The assessment indicated the resident had not had any falls since the completion of the prior assessment. The assessment indicated a chair and bed alarm was used on a daily basis. Review of the medical record revealed no assessment for the use of the bed and chair sensor alarm. Review of the monthly physician orders for August 2023 identified orders dated 05/15/23 pressure sensor alarm to bed at all times, check placement and function every shift. Further review of the physician orders revealed no order for the pressure sensor alarm to wheelchair. Review of the resident's plan of care revealed no care plan for the pressure sensor alarm to the resident's wheelchair. On 08/16/23 at 2:15 P.M., observation of the resident revealed he was sitting in his wheelchair in his room with a pressure sensor alarm. On 08/16/23 at 2: 25 P.M., interview with State Tested Nursing Assistant (STNA) #500 revealed the resident has always had a chair alarm and when a resident has a bed alarm, they have a chair alarm. The STNA revealed the chair alarm is used on a daily basis to alert staff of attempts of unassisted ambulation. On 08/16/23 03:18 PM, interview with Director of Clinical Services (DCS) verified the resident had a pressure sensor alarm in place with no order or assessment of the alarms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews the facility failed to appropriately identify and report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64. Residents Affected - Few Findings include: Record review of Resident #39 revealed an admission date of 07/13/20 with pertinent diagnoses of: Bipolar disorder, depression, hypertension, seizures, muscle weakness, falls, COVID-19, lack of coordination, dementia, traumatic brain injury, and alcohol abuse. Review of the 07/11/23 annual Minimum Data Set (MDS) revealed the resident has severe cognitive impairment and is rarely/never understood. The resident required one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility. Review of progress note from 08/01/23 revealed another resident went into this resident's room and Resident #39 threw his water cup at the other resident, striking him on the cheekbone under his left eye. This caused a small laceration to the resident who walked into the room of Resident #39. Review of Self-Reported Incident revealed a staff member checked the room of Resident #39 after hearing a noise on 08/01/23. Resident #33 was observed leaving the room with a wet shirt with a cup of ice water everywhere on the floor. Approximately 5 minutes later, Resident #33 was observed with a small laceration below his left eye. The incident was unwitnessed by staff at the time of occurrence. Care was provided to both residents. During investigation, discovery was made that the incident was unwitnessed and the staff member was adding details to what they thought might have happened. All staff were reeducated on abuse and neglect policy. Skin assessments were completed for all residents. This report was initiated two days after the incident had occurred on 08/03/23. Interview with Registered Nurse #300 on 08/17/23 at 12:48 P.M. verified delay in reporting to the State Agency of 2 days and not following facility policy as this event occurred on 08/01/23 and was not reported to state agency until 08/03/23. Also verified the facility did not follow policy on reporting of possible abuse as this incident should have been reported on 08/01/23 when it occurred. Review of Facility Abuse Investigation and Reporting Policy revised in July 2017. It states under reporting that all alleged violations of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin will be reported immediately but not later than 2 hours if the allegation involves abuse or resulted in bodily injury; or 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews, the facility failed to appropriately report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64. Findings include: Record review of Resident #39 revealed an admission date of 07/13/20 with pertinent diagnoses of: Bipolar disorder, depression, hypertension, seizures, muscle weakness, falls, COVID-19, lack of coordination, dementia, traumatic brain injury, and alcohol abuse. Review of the 07/11/23 annual Minimum Data Set (MDS) revealed the resident has severe cognitive impairment and is rarely/never understood. The resident required one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility. Review of progress note from 08/01/23 revealed another resident went into this resident's room and Resident #39 threw his water cup at the other resident, striking him on the cheekbone under his left eye. This caused a small laceration to the resident who walked into the room of Resident #39. Review of Self-Reported Incident revealed a staff member checked the room of Resident #39 after hearing a noise on 08/01/23. Resident #33 was observed leaving the room with a wet shirt with a cup of ice water everywhere on the floor. Approximately 5 minutes later, Resident #33 was observed with a small laceration below his left eye. The incident was unwitnessed by staff at the time of occurrence. Care was provided to both residents. During investigation, discovery was made that the incident was unwitnessed and the staff member was adding details to what they thought might have happened. All staff were reeducated on abuse and neglect policy. Skin assessments were completed for all residents. This report was initiated two days after the incident had occurred on 08/03/23. Interview with Registered Nurse #300 on 08/17/23 at 12:48 P.M. verified delay in reporting to the State Agency of 2 days and not following facility policy as this event occurred on 8/1/23 and was not reported to state agency until 08/03/23. Also verified the facility did not follow policy on reporting of possible abuse as this incident should have been reported on 08/01/23 when it occurred. Review of Facility Abuse Investigation and Reporting Policy revised in July 2017. It states under reporting that all alleged violations of abuse, neglect, exploitation, mistreatment, or injuries of unknown origin will be reported immediately but not later than 2 hours if the allegation involves abuse or resulted in bodily injury; or 24 hours if the incident does not involve abuse and has not resulted in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, and staff interview the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) was completed following a new mental health diagnosis. This affected two (Resident #1 and #42) residents of four residents reviewed for PASARR. The facility census was 64. Findings include: 1. Record review of Resident #1 revealed an admission date of 08/20/10 with pertinent diagnoses of: alcoholic cirrhosis of liver without ascites, schizophrenia, obsessive-compulsive personality disorder, and hypertension. Review of the 07/03/23 annual Minimum Data Set (MDS) revealed the resident is cognitively intact and requires extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident requires one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility and is always continent of bowel and bladder. Review of the medical record on 08/15/23 at 8:44 A.M. revealed Resident #1 had a diagnosis of schizophrenia from 10/01/16. Review of the medical record on 08/15/23 at 8:50 A.M. revealed there was never updated an PASARR since 07/09/10 to include the new diagnosis of schizophrenia. Interview with Registered Nurse (RN) #300 on 08/16/23 at 2:45 P.M. verified there was never an updated PASARR completed when the resident had a new diagnosis of schizophrenia. 2. Record review of Resident #42 revealed an admission date of 08/21/20 with pertinent diagnoses of: dementia, diabetes mellitus type II, muscle weakness, acute kidney failure, hypokalemia, anxiety, depression, and unspecified psychosis. A diagnosis of mood disorder was also added on 09/30/20. Review of the 07/01/23 annual Minimum Data Set (MDS) revealed the Resident has severe cognitive impairment and requires extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident requires one person limited assistance for personal hygiene and physical help in part of bathing. The resident uses a wheelchair to aid in mobility and is always continent of bowel and bladder. Review of most recent PASARR completed on 08/16/23 revealed inaccurate indications of mental illness with an omission of mood disorder and Depakote not captured as a Mood Stabilizer in Section 6 of the PASARR documentation. Previous PASARR completed was on 05/13/20 with no indications of mental illness. Interview with RN #300 on 08/16/23 at 2:45 P.M. verified that the newly created documentation did not contain an accurate reflection of PASARR requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Residents Affected - Few Resident #15, #17, and #55 who required assistance with activities of daily living (ADL) received shaving assistance. This affected three (Resident #15,#17, and #55) of four residents reviewed for ADL. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #15 revealed an initial admission date of 09/08/11 with the latest readmission of 04/17/16 with the diagnoses including major depressive disorder, anxiety disorder, insomnia, palliative care, dementia with behavioral disturbance, undifferentiated schizophrenia, dysphagia, psychosis, hypertension, pain, contracture of right ankle, contracture of left ankle, anemia, restlessness and agitation, retention of urine, viral hepatitis C, convulsions, delusional disorder and personal history of traumatic brain injury. Review of the plan of care dated 03/20/23 revealed the resident had a self-care deficit related to activity intolerance, confusion, dementia, fatigue, impaired balance, limited mobility, pain, shortness of breath, depression, anxiety, schizophrenia, psychosis, cognitive deficits, hypertension, muscle weakness, contracture status, hepatitis C, convulsions, delusions, traumatic brain injury, fluctuation with activities of daily living expected with disease process, unable to educate on use of call light related to cognition, unable to use call light appropriately and unable to effectively make needs/wants known. Interventions included staff to anticipate and meet all needs and requires one staff assist with personal hygiene. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had hallucination. The resident required limited assistance with personal hygiene including shaving. On 08/15/23 at 10:11 A.M., observation of Resident #15 revealed he had several days of facial hair growth. On 08/12/23 at 12:45 P.M., observation of Resident #15 revealed he had several days of facial hair growth. On 08/16/23 at 2:10 P.M., interview with State Tested Nursing Assistant (STNA) #502 verified the resident had several days of facial hair growth and required staff assistance with shaving. 2. Review of the medical record for Resident #17 revealed an initial admission date of 06/24/21 with the latest readmission of 07/20/22 with diagnoses including schizoaffective disorder bipolar type, hypertension, chronic obstructive pulmonary disease (COPD), abnormal posture, generalized muscle weakness, constipation, dependence on supplemental oxygen, sexual dysfunction, neuromuscular dysfunction of bladder, dementia, bipolar disorder, major depressive disorder, benign prostatic hyperplasia with lower tract symptoms, insomnia, palliative care, repeated falls, catatonic disorder, dysphagia, psychoactive substance abuse, anxiety disorder, psychosis and opioid dependence. Review of the plan of care dated 03/21/23 revealed the resident had a self-care deficit related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 activity intolerance, confusion, dementia, fatigue, limited mobility, limited range of motion, shortness of breath, schizophrenia, hypertension, COPD, bipolar disorder, depression, pyelonephritis, muscle weakness, lack of coordination, encephalopathy, anxiety, psychosis, opioid dependence, fluctuations expected with activities of daily living (ADL) expected with disease process. Interventions included extensive assistance of one staff with personal hygiene. Residents Affected - Few Review of the resident's MDS dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had delusions, displayed verbal behaviors directed towards others and wandered. The resident required extensive assistance of one with bed mobility, transfers, toilet use and personal hygiene, including shaving. On 08/14/23 at 2:38 P.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/15/23 at 10:35 A.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/16 at 2:00 P.M., observation of Resident #17 revealed he had several days of facial hair growth. On 08/16/23 at 2:10 P.M., interview with STNA #502 verified the resident had several days of facial hair growth and required staff assistance with shaving. 3. Review of the medical record for Resident #55 revealed an initial admission date of 04/07/22 with the latest readmission of 05/13/23 with diagnoses including sepsis, anterior displaced type II dens fracture with delayed healing, chronic viral hepatitis, insomnia, tobacco use, Alzheimer's disease, generalized muscle weakness, shortness of breath, difficulty in walking, unsteadiness, dysphagia, dementia with behavioral disturbances, disorders of bladder, neurogenic bladder, hypertension and atrial fibrillation. Review of the plan of care dated 03/03/23 revealed the resident had a self-care performance deficit related to activity intolerance, Alzheimer's, confusion, dementia, fatigue, impaired balance, limited mobility, atrial fibrillation, hypertension, behavioral disturbances, fluctuations in activities of daily living (ADL) performance expected with disease progression, unable to educate on use of call light related to cognition, unable to use call light appropriately and unable to effectively make needs known. Interventions included resident is dependent on one staff for personal hygiene. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident required extensive assistance of one for personal hygiene including shaving. On 08/14/23 at 1:31 P.M., observation of Resident #55 revealed he had several days of facial hair growth. On 08/15/23 at 10:37 A.M., observation of Resident #55 revealed he had several days of facial hair growth. On 08/16 at 2:05 P.M., observation of Resident #55 revealed he had several days of facial hair growth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 On 08/16/23 at 2:10 P.M., interview with STNA #502 verified the resident had several days of facial hair growth and required staff assistance with shaving. 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 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 Based on record review and interview, the facility failed to ensure one resident (#65) who received antihypertensive medications with parameters for blood pressure (BP) was obtained prior to administration. This affected one (Resident #65) of five residents reviewed for unnecessary medications. The facility census was 64. Residents Affected - Few Findings Include: Review of the medical record for Resident #65 revealed an initial admission date of 04/12/23 with the admitting diagnoses including chronic obstructive pulmonary disease (COPD), dementia, low back pain, dysphagia, major depressive disorder, benign prostatic hyperplasia, neutropenia, psychosis, gastro-esophageal reflux disease, malignant neoplasm of pharynx, hypertension, convulsions and type I diabetes mellitus. Review of the resident's plan of care revealed no care plan addressing the resident's diagnosis of hypertension. Review of the resident's monthly physician's orders for August 2023 identified orders dated 04/12/23 for Lisinopril 2.5 milligrams (mg) via gastric tube with the special instructions to hold the medication if the systolic blood pressure is less than 90 or heart rate less than 60. All labs completed as ordered, however the resident refused labs frequently. Review of the Medication Administration Record (MAR) for June, July and August 2023 revealed the staff nurses had not obtained the resident's blood pressure and pulse prior to administration of the medication Lisinopril. On 08/15/23 at 4:40 P.M., interview with the Director of Clinical Services (DCS) verified the staff nurses had not obtained the resident's blood pressure and pulse prior to the administration of the Lisinopril. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to provide a safe, comfortable environment for Resident #18 when his wall was cracked and the heater was rusted and for Resident #42 when his room walls needed painted and patched. This affected two Residents (Resident #18 and #42) of five residents reviewed for environment. The facility census was 64. Findings include: Observation on 08/17/23 at 12:46 P.M. of Resident #42's room revealed there was a large area by the bed that the drywall was damaged and needed repaired. This was verified with Registered Nurse #300 at the time of the observation. Observation on 08/17/23 at 12:55 P.M. of Resident #18's room revealed there was a crack in the wall that needed repaired and the heater was rusted and needed painted. This was verified with Registered Nurse #300 at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365932 If continuation sheet Page 12 of 12