Health inspection·September 5, 2019

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on record review, review of facility policy and staff interview, the facility failed to ensure baseline care plans were completed in 48 hours and a copy was provided to the resident. This affected one (Resident #44) of one resident reviewed for baseline care plans. The facility census was 40. Findings Include: Review of the medical record for Resident #44 revealed an admission date of 07/03/19 with diagnoses including congestive heart failure, chronic respiratory failure and chronic kidney disease. Review of the interim care plan for Resident #44 revealed it was started and completed on 07/08/19. There was no indication in the medical record that Resident #44 was provided with a copy of the interim care plan. Interview with Minimum Data Set Coordinator #30 on 09/05/19 at 1:01 P.M. verified the baseline care plan was not started and completed until 07/08/19 and the resident did not receive a copy of the baseline care plan. Review of the undated policy titled Care Plans-Preliminary revealed to assure that the residents immediate care needs are met and maintained, and a preliminary care plan is developed upon admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 2 of 7 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 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 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 review of the medical record and staff interview, the facility failed to ensure a resident receiving psychotropic medications had a comprehensive care plan with measurable objectives and interventions to ensure appropriate care was being provided, a resident with multiple falls had a comprehensive care plan with appropriate goals and outcomes, and a resident with congestive heart failure and chronic respiratory failure had a comprehensive care plan with measurable objectives and interventions. This affected three (Resident #8, #9 and #44) of 12 residents reviewed for comprehensive care plans. The facility census was 40. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted on [DATE] with diagnoses to include anxiety disorder, major depression, fibromyalgia, insomnia and Alzheimer's disease. Review of the physician's orders, dated 03/19/19, revealed an order for Trazadone (antidepressant) 50 milligrams (mg.) one tablet by mouth at bedtime for insomnia written on 03/19/19. A physician order, dated 08/07/19, revealed an order for Melatonin tablet three mg. at bedtime for insomnia. Review of the care plan revealed the care plan did not include the resident was having difficulty with insomnia and therefore did not have any non-pharmalogical interventions to promote sleep without using medications and/or using [NAME] medications to treat the residents symptoms of insomnia and monitoring the resident for insomnia. Interview with Minimum Data Set (MDS) Coordinator #30 on 09/04/19 at 1:12 P.M. confirmed there was no care plan for insomnia. She stated she was sure the nurses would be monitoring her sleep and the resident was able to tell them. She agreed there was no evidence in the medical record of the resident not being able to sleep or any interventions to help promote sleep. 2. Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive lung disease, major depression disorder and hallucinations. On 06/09/19, the resident was diagnosed with senile degeneration of the brain and was noted to exhibit short-term and long-term memory loss. Review of the quarterly Minimum Data Set (MDS) assessment revealed Resident #9 was cognitively intact in 01/2019 and was cognitively impaired in 06/2019. Review of Resident #9's plan of care, last revised on 08/29/19, revealed the resident was a high risk for falls related to deconditioning, gait and balance problems, limited mobility, muscle weakness and has had repeated falls. With interventions, the resident was to be free of falls through the next review date of 10/03/19. As of 08/29/19, the resident had one fall. The interventions did not include Resident #9's cognitive changes nor were the interventions revised to address her diminished cognitive level to prevent her from falling. Observation of Resident #9 on 09/05/19 at 7:00 A.M. revealed the resident to be in a low bed with a mat. Resident #9's care plan as of 09/05/19 did not include a low bed with a mat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 3 of 7 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 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 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 Interview on 09/04/19 at 5:00 P.M. with the Director of Nursing (DON) and Registered Nurse #2 confirmed the plan of care has not been updated to reflect the changes in Resident #9's cognitive level nor does it reflect new interventions to prevent further falls for someone who displayed increased cognitive impairment. 3. Review of the closed medical record for Resident #44 revealed an admission date of 07/03/19 with diagnoses including chronic respiratory failure, congestive heart failure and chronic kidney disease. Review of the nurse's note, dated 07/25/19 at 1:24 P.M., revealed at 1:10 P.M. Resident #44 was complaining of shortness of breath and pressure in his chest and wanted to be sent out to the hospital. There was no comprehensive care plan in place for the resident's chronic respiratory failure and congestive heart failure. Interview with MDS Coordinator #30 on 09/05/19 at 1:01 P.M. verified Resident #44's comprehensive care plan did not address congestive heart failure and chronic respiratory failure. Review of the undated policy titled Care Plans-Comprehensive revealed the comprehensive care plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, reflect treatment goals and objectives in measurable outcomes, identify the professional services that are responsible for each element of care, prevent declines in the resident's functional status and/or functional levels, and enhance the optimal functioning of the resident by focusing on a rehabilitative program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 4 of 7 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 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on review of the facility's Daily Staffing Information Sheet, observation and staff interview, the facility failed to ensure that daily staffing was posted with the correct daily census number and the actual hours worked by staff for resident care was completed each shift. This had the potential to affect all 40 residents who resided in the facility. Residents Affected - Many Findings include: Observation during the initial tour on 09/03/19 at 9:00 A.M. revealed the daily Staffing Information Sheet was posted at the nurse's station located in the back of the building on the rehabilitation unit. Review of the sheet revealed it was dated and completed for the entire week 09/02/19 to 09/06/19 with a census of 50 each day. The nursing hours were not included on the form to reflect the actual hours worked for each shift. Interview on 09/03/19 at 1:35 P.M. with the Director of Nursing revealed on 09/03/19, the facility census was 41, on 09/04/19, the facility census was 44 and on 09/05/19, the facility censuses was 45. The DON did not realize the sheet needed to include actual hours worked for each shift and confirmed the census was not updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 5 of 7 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 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident receiving psychotropic medications was assessed for the need and continued need of the medications which included monitoring of behaviors. This affected one (Resident #8) of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: Review of the medical record for Resident #8 revealed the resident was admitted on [DATE] with diagnoses to include anxiety disorder, major depression, insomnia and Alzheimer's disease. Review of the physician's orders revealed an order to increase Buspirone 7.5 milligram (mg.) by mouth for anxiety, three times a day written on 08/21/19. Melatonin tablet three mg. was at bedtime for insomnia was added on 08/07/19. Trazadone 50 mg. (antidepressant) one tablet by mouth at bedtime for insomnia written on 03/19/19. Review of the nursing progress notes, dated 08/21/19, revealed the resident complained of increased anxiety, the cause was unknown and the physician/nurse practitioner was made aware. The physician/nurse practitioner increased Buspirone to 7.5 mg. three times a day. Review of the care plan revealed the care plan did not include the presence of insomnia. There was no assessment completed to determine the cause of the insomnia or any non-pharmalogical interventions to help promote sleep. Further review of the resident's medical record revealed there was no evidence the resident was monitored for anxiety behaviors. The medications were increased on 08/21/19 for increased anxiety but no increased anxiety was noted in the record by the nursing staff. Interview with Registered Nurse #560 on 09/04/19 at 1:12 P.M. confirmed there was no evidence in the medical record of the resident not being able to sleep or any interventions to help promote sleep. She confirmed there was no assessment completed to determine the cause of the insomnia. Interview with the Director of Nursing on 09/05/19 at 8:30 A.M. stated they only monitor behaviors with medications that were ordered as needed and not for scheduled medications. She confirmed they increased the anti-anxiety medication on 08/21/19 and there was only the one documentation of increased anxiety. She agreed the increased anxiety entry by the nurse did not include what symptoms the resident was experiencing or for how long, if this was a one time experience or if there were any non-pharmacological interventions attempted prior to getting the anti-anxiety medication increased. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 6 of 7 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 365988 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Brook Christian Home 55 Lazelle Rd Columbus, OH 43235 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to have hospice services documentation addressed on residents' charts. This affected one (Resident #9) of one resident reviewed for hospice services. The facility identified eight residents receiving hospice services. The facility census was 40. Findings include: Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive lung disease. Review of the medical record revealed Resident #9 was admitted to Hospice Entity #505 on 06/09/19 with a diagnosis of senile degeneration of the brain. Review of the hospice binder for Hospice Entity #505 revealed there were no hospice progress notes for Resident #9 available since 06/25/19. Interview on 09/05/19 at 9:30 A.M. with the Director of Nursing verified no hospice progress notes since 06/25/19 were available in the facility. Telephone interview on 09/05/19 at 1:20 P.M. with Hospice Supervisor #510 revealed they do not leave progress notes in the facility after each visit. Review of the facility-hospice agreement with Hospice Entity #505, dated 11/27/18, revealed the facility and hospice will prepare and maintain complete medical records for hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed and maintained in the facility chart FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 7 of 7