Inspection·February 28, 2022

F 0609 report this incident to anyone. Level of Harm - Minimal harm or potential for actual harm Interview on 02/22/22 at 12:00 P.M., with the Administrator revealed he was unaware of Resident #9 reporting the incident to STNA #132 and the surveyor notified the Administrator of the allegation of abuse/neglect for Resident #9. The Administrator verified the facility did not report the alleged incident to the state agency. Residents Affected - Few Review of the SRI #218237, initiated on 02/22/22 at 7:08 P.M., for physical and verbal abuse revealed an ODH Surveyor during the facility annual survey, interviewed residents. The surveyor stated that Resident #9 made an allegation regarding possible emotional/verbal abuse and rough care. Surveyor indicated that the resident stated an STNA had said things that upset her regarding her needing personal assistance with personal care. The allegation was substantiated with corrective action taken. Review of the policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed abuse is defined as the willful infliction of injury, confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, and it also includes the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Administrator should be notified by informing him/her in person, calling via telephone, or sending an email or text message. It further stated the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegations is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 2 of 13 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 02/28/2022 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately reflect resident wounds. This affected two (#19 and #32) of three reviewed for resident assessments. The facility census was 44. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #32 revealed an admission on [DATE], with diagnoses including hypertension, hyperlipidemia, peripheral vascular disease, major depressive disorder, gastro-esophageal reflux disease without esophagitis, type two diabetes mellitus, and personal history of other venous thrombosis and embolism. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 had intact cognition. Review of the assessment revealed Resident #32 did not have any unhealed pressure ulcers or injuries. Resident #32 was identified as having a diabetic foot ulcer. Review of the wound note dated 01/10/22 for Resident #32 revealed she did not have a diabetic foot ulcer. Resident #32 was listed as having a stage two pressure ulcer and an unstageable pressure ulcer. Interview on 02/23/22 at 2:10 P.M., with MDS Nurse #107 confirmed Resident #32 had been coded as having a diabetic wound when she had pressure ulcers. 2. Review of the medical record revealed Resident #19 revealed an admission on [DATE], with diagnoses including type two diabetes mellitus, personal history of pulmonary embolism, bipolar disorder, dysphagia, other schizoaffective disorder, major depressive disorder, anemia, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 did not have any unhealed pressure ulcers or injuries. The resident was identified as having a diabetic foot ulcer and infection of the foot. Review of Resident #19's wound note dated 12/20/21 revealed the resident had an unstageable pressure ulcer to his left heel and traumatic wounds to his left thigh, shin, knee, and 1st metatarsal. Interview on 02/23/22 at 2:10 P.M., with MDS Nurse #107 confirmed Resident #19's wounds were coded incorrectly. She stated she had realized it had not been documented correctly on 02/22/22 and had begun a modification of the assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 3 of 13 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 02/28/2022 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident. This affected one (#19) of one resident reviewed for PASARR. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record revealed Resident #19 revealed an admission of 12/16/21, with diagnoses including type two diabetes mellitus, personal history of pulmonary embolism, bipolar disorder, dysphagia, other schizoaffective disorder, major depressive disorder, anemia, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition. Review of the medical record for Resident #19 on 02/22/22 at 11:00 A.M., revealed no evidence a Preadmission Screening and Resident Review (PASARR) had been completed following admission. Review of the PASARR dated 02/22/22 revealed the assessment was completed due to an expiring hospital exemption. Interview on 02/23/22 at 11:22 A.M., with Social Worker #179 confirmed hospital exemptions were to be completed within 30 days of admission and she had completed his on 02/22/22, which was outside of 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 4 of 13 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 02/28/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, family interview, and policy review, the facility failed to monitor resident's skin impairments and edema. This affected four (#6, #9, #13, and #40) of four residents reviewed for skin impairments. The census was 44. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 11/22/21 and the diagnoses of elevated liver enzymes, chronic obstructive pulmonary disease, volvulus, syncope and collapse, encephalopathy, and bipolar disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required limited assistance of one staff for bed mobility, extensive assistance of one staff for transfers, locomotion, toilet use and personal hygiene. Review of the care plan dated 12/08/21 revealed Resident #9 had an activities of daily living (ADL) self-care performance deficit related to weakness, syncope, demyelating disease and diarrhea with interventions to provide a sponge bath when a full bath or shower cannot be tolerated, extensive assistance with bed mobility, and skin inspections: the resident requires skin inspections daily with care and twice weekly with bathing/showering, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Review of Resident #9's shower sheets/skin observations revealed on 02/08/22, 02/12/22, and 02/15/22 the resident refused showers, therefor skin assessments were not completed. On 02/22/22, the skin observation sheet stated the resident refused her shower but a bruise was noted to her left shoulder. Review of the nurses notes revealed on 02/14/22, Resident #9 fell on the previous shift and the residents left shoulder was now swollen and she was unable to move the arm. Pain medications were given with positive effect and she denied to go to the hospital. The physician was notified and ordered an X-ray. On 02/14/22, Resident #9's X-ray showed a fracture of the surgical neck, the physician was notified and arrangements were made for the resident to see an orthopedic doctor. The residents family was also notified. On 02/22/22 at 8:00 P.M., the resident continued to refuse showers and bed baths. On 02/23/22 at 1:57 P.M., the resident was assessed to have bruises on her left upper arm believed to be a delayed injury from a previous fall. The residents family and physician were notified and it will be monitored per her care plan. On 02/24/22 at 10:43 A.M., the bruises to her left arm were still present and not looking worse. There were no open areas or swelling and she is on daily aspirin. Observation and interview on 02/22/22 at 11:37 A.M., with Resident #9 revealed staff does not monitor her left arm bruise. She stated she has a fractured shoulder from a fall and that's where the bruise came from. The bruise was approximately the size of a baseball above her left elbow and was light to medium purple in color. Interview on 02/23/22 at 11:52 A.M., with the Director of Nursing (DON) revealed Resident #9's X-ray stated she had a subtle hairline fracture to the surgical neck of the left humorous. The orthopedic physician did not recommend any surgical interventions, only a sling as tolerated. She stated staff are monitoring the bruise as needed and the aides complete skin assessments when they give them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 5 of 13 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 02/28/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some showers, then the nurses sign off on the skin assessments. The DON later stated they were not monitoring the bruise because they know how it occurred, but when the nurses give her medications they're suppose to monitor it. If it was getting worse they would know, even without continuous documentation. Review of the physician orders dated 02/23/22 revealed a new order to monitor the left upper arm bruises every shift and notify the physician if it worsened. Interview on 02/24/22 at 9:41 A.M., with the DON revealed in the event that a resident refused a shower, the aides are suppose to fill out a form saying they refused, but they still receive a skin assessment and should still be documenting what they see. She confirmed Resident #9 had three shower refusals recently and no documented skin assessments. The surveyor showed her the aide skin assessment from 02/22/22 which stated the resident had bruising to left shoulder. The DON nodded her head yes that the location of the bruise was to the left elbow, not shoulder, but she then refused to confirm that saying the bruise is just on the arm. The DON then stated, Aides don't know anatomy, but further confirmed the aides are the ones completing the resident's skin assessments. 2. Review of the medical record for Resident #40 revealed an admission date of 01/21/21 and the diagnoses of diabetes type two, difficulty walking, muscle weakness, high blood pressure, obesity, chronic kidney disease (CKD) stage three, hemiplegia and hemiparesis affecting left non-dominant side, depression, and frontotemporal dementia. Review of the annual MDS assessment dated [DATE], revealed the resident had moderate cognitive impairment and required total dependence of two staff for bed mobility, transfers, total dependence of two staff for toilet use and limited assistance of two staff for personal hygiene. It further stated the resident had no wounds and was at risk for pressure ulcers. Review of the care plan dated 05/10/21 revealed Resident #40 had an activities of daily living (ADL) self-care performance deficit related to hemiplegia, impaired balance, and history of cardio vascular accident with interventions to perform skin inspections: the resident requires skin inspections daily with care and twice weekly with bathing/showering, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. It further stated the resident had the potential for impairment to skin integrity related to fragile skin, urinary incontinence and mobility deficits with interventions to follow facility protocols for treatment of injuries. Review of Resident #40's most recent shower sheets/skin observation dated 02/14/22 revealed the resident refused a shower/skin check. There were no other more recent skin assessments provided. Observation and interview on 02/22/22 at 11:12 A.M., with Resident #40 revealed the right thumb and knuckle was dark red and dark purple. Resident #40 stated she was not sure how it happened but that staff may have agitated it when she got out of bed, she stated she is on an anticoagulant and staff don't monitor the bruised area. Interview on 02/23/22 at 3:45 P.M., with Registered Nurse (RN) #111 revealed last week either Tuesday (02/15/22) or Wednesday (02/16/22), Resident #40 had a blood draw and had tape and gauze on that area on her right hand. She stated she worked Monday (02/21/22) and there was a very slight, very faint bruise. She stated there was nothing in report about it and she didn't notify anyone about it, she just passed it on for nurses to monitor it. She stated she didn't think it was anything major because the resident just had blood work and she is on aspirin. She stated the monitoring of skin is based on team work with aides and nurses, aides do the skin checks on the shower days, and there were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 6 of 13 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 02/28/2022 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 0684 no signs of pain and she was able to use that hand with no trouble. Level of Harm - Minimal harm or potential for actual harm Interview on 02/23/22 at 12:35 P.M., with State Tested Nurse Assistant (STNA) #151 revealed she noticed the bruise Tuesday (02/22/22) and told the nurse immediately. The nurse assessed it and Resident #40 said she scratched it. When the residents daughter came in that Tuesday she said that the wound had probably been there a while because it was so dark (which is not accurate for bruising). Residents Affected - Some Interview on 02/23/22 at 12:24 P.M., with RN #110 revealed an aide told her about Resident #40's bruise on 02/22/22, and she assessed it, but she doesn't know where it came from. She confirmed she didn't notify the physician because she figured all of the appropriate notifications were made because the daughter was aware, and she also stated she thought everyone was aware besides her. Review of the nurses notes dated 02/23/22 at 4:22 P.M., revealed on 02/22/22, an STNA reported to the nurse, bruising to Resident #40's right thumb and hand. There were no complaints of pain. The resident said her daughter was aware, there was a blood was draw on 02/15/22 and the physician was notified of the bruise. A new order was received to monitor the bruise. Interview on 02/23/22 at 12:05 P.M., with the Director of Nursing (DON) revealed she was not notified of a bruise until now and she was not sure how Resident #40 got the bruise. She stated she expected staff to notify her if there was a new bruise. Review of the physician monthly orders revealed orders for Aspirin 81 milligrams (mg) daily for prevention. Review of the new physician orders dated 02/24/22, revealed the resident had a new order to monitor the bruise to her right thumb, wrist, and hand daily until resolved. Interview on 02/24/22 at 8:56 A.M., with Family Member #1 revealed she saw Resident #40's right hand on Tuesday (02/22/22), it was a swollen bruise that was a darker purple like it was new. She stated she is a hospital nurse. She further stated when she came in Tuesday the aide told her about it and said she notified the nurse, but she was unsure if the physician was notified. She stated Resident #40 was unaware how it occurred but stated maybe it was from when staff were getting her up or something. She stated she was not notified prior to Tuesday about the bruise, there were no signs of pain, and she saw her at the facility Saturday (02/19/22) or Sunday (02/20/22). Interview on 02/24/22 at 9:41 A.M., with the DON revealed in the event that a resident refused a shower, the aides are suppose to fill out a form saying they refused, but they still receive a skin assessment and should still be documenting what they see. She confirmed Resident #40's most recent documented skin assessment was 02/14/22. 3. Review of the medical record for Resident #13 revealed an admission date on 06/21/21. Medical diagnoses included fracture of T11-T12 vertebra, type II Diabetes Mellitus, heart failure, and unspecified dementia without behavioral disturbance. Review of quarterly MDS assessment dated [DATE] revealed Resident #13 had moderately impaired cognition and required extensive assistance to total dependence on staff to complete Activities of Daily Living (ADLs). There were no skin issues noted in the assessment. Review of the care plan revised 12/06/21 revealed bruising to Resident #13's forearms and hands was not addressed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 7 of 13 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 02/28/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician orders for February 2022 revealed Resident #13 did not have any orders for monitoring the bruising on both forearms and hands. Resident #13 did not have any orders for anticoagulant medications. Resident #13 was admitted to hospice services on 09/02/21. Review of progress notes dated from admission on [DATE] to current revealed no indication of Resident #13's bruising to his forearms and hands. Review of resident assessments since admission on [DATE] to current revealed there were no skin observation assessments completed related to the bruising on the resident's forearms and hands. Review of the shower sheets/skin assessment sheets dated from 01/02/22 through current revealed the bruising on Resident #13's hands and forearms was not identified on any of the shower/skin sheets. Review of the hospice notes dated from 10/26/21 through current revealed the bruising on Resident #13's forearms and hands was not addressed. Observations of Resident #13 on 02/22/22 at 12:32 P.M. and 02/23/22 at 11:10 A.M., revealed Resident #13 had scattered bruising on bilateral hands and forearms from the back of his palms up to his elbows. The bruise varied in size and color with some bruises being dime-size and others being quarter-size with colors ranging from deep purple to a green-yellowish color. Interview on 02/23/22 at 11:10 A.M., with Resident #13 revealed the resident could not recall how he obtained the bruises on both arms and hands. Resident #13 reported he had discomfort sometimes from the marks. Resident #13 reported he tried not to bump into things if he could help it. Resident #13 stated, Everybody knows they are there but has not done anything about it. Interview on 02/23/22 at 11:23 A.M., with Registered Nurse (RN) #110 revealed she was familiar with Resident #13 and had provided care for him before. RN #110 stated Resident #13 always had bruising. RN #110 stated there had not been any changes with the bruising. RN #110 confirmed Resident #13 was not taking any anticoagulant medications and was not sure what the cause of the resident's bruising on his forearms and hands was. RN #110 stated she did not complete any regular skin checks or monitoring of the bruising. RN #110 stated the nurse aides completed skin assessments during shower days but nurses did not complete skin assessments. Interview on 02/23/22 at 11:37 A.M., with RN #112 revealed the facility's protocol for a resident with bruising and not on any anticoagulant medication included conducting an investigation to determine the cause of the bruising and rule out any abuse to the resident. Then, the bruising should be documented in the nurse notes. RN #112 stated continued monitoring of the bruising should be documented in the progress notes, including any changes or newly identified areas. Interview on 02/23/22 at 12:45 P.M., with the Director of Nursing (DON) confirmed Resident #13's bruising on both of his forearms and hands had not been monitored. 4. Review of the medical record for Resident #6 revealed the resident admitted on [DATE] with diagnoses including chronic kidney disease, hyperlipidemia, anxiety disorder, major depressive disorder, osteoporosis, occlusion of stenosis, atherosclerotic heart disease, and fracture of unspecified part of neck of right femur. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 had intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 8 of 13 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 02/28/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the plan of care dated 09/07/21 revealed the resident had hypertension. Interventions included monitoring for any signs of malignant hypertension, monitor abnormalities for urinary output, monitor for and document any edema and notify doctors, and give antihypertensive medications as ordered. Review of the plan of care dated 02/22/22 revealed the resident had a potential or actual impairment to skin the heels/buttocks related to edema, fragile skin, surgical wound, suspected deep tissue injury to the right heel. Interventions included applying pressure reduction boots while in bed, avoiding scratching and keeping hands and body parts from excessive moisture, follow facility protocols for treatment of injury, encourage good nutrition and hydration, identify and document potential causative factors and eliminate resolve where possible, use caution during transfers and bad mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of the medical record from 02/01/22 to 02/22/22 revealed nothing related to Resident #6's bruising or the edema on her hands. Review of the skin observation tool dated 02/21/22 revealed Resident #6 had a pressure ulcer to her right heel. No other skin issues were identified. Review of the progress note dated 02/23/21 at 12:21 P.M. revealed Resident #6 was assessed to have some swelling in her left hand. She was encouraged to elevate her hand and the physician was notified. The note indicated the area would be monitored. On 02/24/22 at 12:14 P.M. revealed Resident #6's left hand still had some swelling and bruising. The are did not look worse and the skin was intact. The note stated the resident was on Plavix and Aspirin. Review of the 01/28/22 thru 02/20/22 revealed skin observation revealed Resident #6 refused, there was no documentation related to the condition of her skin. Observation of Resident #6 on 02/22/22 at 2:36 P.M. and on 02/23/22 at 12:11 A.M., revealed the resident had black and purple bruising to her bilateral hands the bruising covered most of the back of her hand. Additionally, Resident #6 had swelling to her left hand and fingers. Interview with Resident #6 on 02/22/22 at 2:36 P.M., revealed she was unsure how she got the bruising or swelling and was unsure how long it had been going on. Interview on 02/23/22 at 8:26 A.M. and 12:11 P.M., with Registered Nurse (RN) #112 revealed she was Resident #6's nurse and had been in to see the resident that day. RN #112 verified the resident had bruising to her bilateral hands that she had already been aware of. RN #112 reported bruises are to be monitored through progress notes. Observation at 12:11 P.M. with RN #112 additionally confirmed Resident #6's left hand was swollen. She reported with new edema they would monitor it and notify the physician if it persisted. RN #112 reported the aides did skin checks during resident care, she stated nurses only did skin checks of aides reported a problem. Interview on 02/23/22 at 8:28 A.M., with RN #110 revealed nurses did not do weekly skin checks. She reported nurses were to assess if aides reported any skin concerns. Interview on 02/23/22 at 12:21 P.M. and on 02/24/22 at 9:41 A.M. with the Director of Nursing (DON) revealed aides are to notify nurses of any skin changes in residents. She confirmed aides should have let nursing know of Resident #6's edema if it had been ongoing since 02/22/22. She revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 9 of 13 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 02/28/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some physician was to be notified of any new onset edema. The DON revealed skin observations are to occur if the resident refuses a shower and if a resident is refusing the skin observation a nurse should be told. The DON confirmed that even when residents refuse full skin observations, aides should document any skin concerns they can observe. The DON confirmed the bruises on Resident #6's hands could be observed without a full skin observation. The DON confirmed that the skin observations did not consistently identify wounds, including ones they were already aware of like Resident #6's pressure ulcer. The DON stated the aides are not very exact. On 02/24/22 at 11:25 A.M., the DON confirmed they had not yet documented on the bruises confirmed by RN #112 the day before, and verified they should have been documented on. Review of the undated policy titled, Care and Prevention of Skin Breakdown, revealed skin observation sheets will be filled out with every shower or bath at least twice weekly, and if a shower or bath is refused the skin will still be checked. They will be signed off by the floor nurse and then passed on to the wound nurse if any issues were identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 10 of 13 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 02/28/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview and policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). There were three medication errors out of 33 opportunities to equal an error rate of 9.09%. This affected three (#4, #6, and #7) of eight residents observed during the medication administration observation. The census was 44. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #4 revealed an admission date of 01/28/12 and the diagnoses of high blood pressure, diabetes type two, fatigue, and heart failure. Review of the monthly physician orders for February 2022 revealed the resident was ordered a stool softener-laxative twice daily for constipation and the order stated in bright red letters Dose check not performed. There was no medication specified and no dosage specified. Observation on 02/22/22 at 3:16 P.M. with Registered Nurse (RN) #117 revealed she administered Senna Plus 8.6-50 milligrams (mg) to Resident #4. Interview on 02/23/22 at 3:37 P.M., with RN #117 confirmed the residents stool softener-laxative medication had no medication specified and no dose on the order, and she further confirmed the Senna medication just came from the pharmacy even with that order not being specific. 2. Review of the medical record for Resident #6 revealed an admission date of 08/18/21 and the diagnoses of chronic kidney disease, high blood pressure, and anxiety. Observation on 02/23/22 at 8:10 A.M., with Registered Nurse (RN) #112 revealed she obtained Resident #6's blood pressure which read 110/60. RN #112 had Resident #6's Lisinopril separated from other medications because it was only administered based on her blood pressure reading. Immediately after taking the blood pressure reading, she administered all other medications and did not administer the Lisinopril, she stated it was being held due to the order stating not to administer for a systolic blood pressure less than 110. Review of the monthly physician orders for February 2022 revealed orders for Lisinopril 20 milligrams (mg) daily with instructions to give one tablet by mouth daily and hold for a systolic blood pressure less than 100. Review of the medication administration record revealed the resident's blood pressure was 100/60 and the medications was held. The documentation was inaccurate based on that same observation. Interview on 02/23/22 at 9:17 A.M., with RN #112 confirmed Resident #6's order was to not administer the medication for a systolic blood pressure below 100, and the medication should not have been held. She stated she would go administer the medication. 3. Review of the medical record for Resident #7 revealed an admission dated of 02/16/18 and the diagnoses of high blood pressure, diabetes, and glaucoma. Review of monthly physician orders for February 2022 revealed orders for Combigan 0.2%-0.5% eye drops, with instructions to administer one eye drop to the right eye twice daily for glaucoma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 11 of 13 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 02/28/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm Observation on 02/23/22 at 7:45 A.M., with Registered Nurse (RN) #110 revealed she administered Resident #7's Combigan eye drops to both eyes. Interview on 02/23/22 at 9:15 A.M., with RN #110 confirmed Resident #7's Combigan eye drop order was for the right eye only. Residents Affected - Few Review of the policy titled, Medication Pass, dated February 2022, revealed nursing duties during medication administration were to check the medication orders in the Medication Administration Record (MAR) against the medication, check the correct medication route, check the correct medication dose, check vital signs as ordered for certain medications, and chart the medications given on the MAR immediately after administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 12 of 13 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 02/28/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to implement Legionella prevention plan according to the facility water management plan. This had the potential to affect 44 of 44 residents in the facility. Facility census was 44. Residents Affected - Many Findings include: Review of the Legionella maintenance plan revealed weekly maintenance plans included weekly water temperature logs of cold water systems, hot water systems, hot water boilers and hot water tanks. The maintenance plan revealed weekly visual inspection of the spa tubs. The maintenance plan revealed monthly visual inspections to be completed of the showerheads and aerators and quarterly plans for visual inspections of the ice machines, water dispensers, and drinking fountains. Interview on 02/24/22 at 9:00 A.M., with Maintenance Director (MD) #188 revealed when a room is vacant for over two weeks, or water source goes unused, the pipes will be flushed for at least five minutes prior to their next use. MD #188 revealed the water drinking fountains were closed during the COVID outbreak and have reopened. MD #188 confirmed no documentation of the water fountains being flushed for 5 minutes prior to use. MD #188 confirmed water temps were last completed on 12/09/21 and confirmed these are to be done weekly. MD #188 confirmed the visual inspections have been completed in the middle of the month and the visual inspection had not been done in about 5-6 weeks. MD #188 revealed these tasks have not been able to be completed due to staffing in the maintenance department. Review of the policy titled Water Management Program dated 09/01/21, revealed the facility would establish water management plans for reducing the risk of Legionella an other opportunistic pathogens in the facilities water system. The policy revealed facility will develop a plan and the water management team should regularly verify the program was being implemented and documentation of all activities should be maintained in the water management binder for three years. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365988 If continuation sheet Page 13 of 13