Health inspection·April 3, 2025

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident Life Director/Sister #450 on 04/03/25 at 1:59 P.M. revealed donating to the DSOP is an understanding that when the residents have a certain amount of money in their account, that is close to the spend down limit, they will donate it back to the DSOP. When asked how much money each resident is expected to donate, she could not answer. When asked how often the residents have to donate, she could not answer. When asked how much money each resident is permitted to keep in their account before they are expected to donate, she could not answer. She stated the residents know they are expected to give/donate back to the DSOP, but they have no documented procedures or education for the residents or resident representatives to outlines the guidelines. She confirmed there was nothing in hard copy provided to the residents/representatives about these procedures of expected/required donations. She stated the residents sign the donation/financial forms to allow the donating. Interview with Administrator at 04/03/25 at 3:11 P.M. revealed she was not aware of the donation process and procedures regarding the director of life and the sisterhood. She confirmed there should be information provided to the residents about any donation, and the resident/representative should approve/sign it. Review of facility Resident Handbook, undated, revealed the facility provides maintenance for individual resident accounts at the facility for the convenience of the resident or responsible party. Residents may use the money in their account for whatever they choose, and are able to withdraw funds from this account at the front desk. The facility is also able to provide checks if the resident prefers. If the resident would like to request a check for a purchase/donation, see the finance manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 2 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 - Some 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** 5. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses osteoarthritis, high blood pressure, and major depressive disorder. Review of Resident #4's physician orders and medication administration records revealed the resident received Clindimycin HCL, an antibiotic, prior to any dental appointments. Review of Resident #4's care plan revealed no focus areas, goals, or interventions for the antibiotic medication. Interview on 04/03/25 at 11:03 A.M. with ADON confirmed Resident #4's care plan did not reflect the antibiotic medications the resident was receiving. 3. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses that included intracranial cerebral hemorrhage, disorder of the urinary system, and need for assistance with personal care. Review of Resident #65's Bowel and Bladder Program Screener assessment dated [DATE] revealed she was a good candidate for bladder retraining. Review of Resident #65's Minimum Data Assessment on 02/04/25 revealed that she was frequently incontinent and had not had a trial of a toileting program since urinary incontinence was noted in the facility. Review of Resident #65's care plan dated 07/12/24 revealed that it was silent for identifying Resident #65 as a risk for bladder incontinence and that it was silent for goals and interventions to prevent further bladder incontinence or improve bladder continence. Interview with Licensed Practical Nurse #150 on 04/02/25 at 8:54 A.M. revealed that he would normally create a care plan for bladder continence with goals and interventions listed on it if a resident was identified as a good candidate for a bladder retraining program. Interview further confirmed that Resident #65's medical record was silent for a bladder continence care plan. 4. Review of the medical record for Resident #9 revealed an admission date of 01/24/17, with diagnoses of Type II Diabetes Mellitus, hypertension, osteoarthritis, muscle weakness, and difficulty walking. Review of minimum data set (MDS) 3.0 assessment completed 06/06/24 revealed resident #9 scored a 14 on brief interview for mental status, indicating the resident was cognitively intact. Additionally the resident exhibited no disorganized thinking or altered level of consciousness, and showed no signs of inattention. Additionally, the resident does not reject care. Review of care plan undated revealed that Resident #9 wears full upper dentures and a partial lower denture and has some of her own teeth. Interventions include continuing to assist with arranging dental appointments, providing transportation, and following up with the dentist as indicated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 3 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 - Some Review of lab result collected on 02/04/25 revealed that the resident refused lab work for the day. We will attempt to obtain specimens two more times, and then will discontinue attempts according to the resident's wishes. Review of active physician orders dated 03/01/25 revealed a standing order for Amoxicillin 500 milligrams, four capsules by mouth as needed prior to dental work. Review lab result collected on 03/04/25 revealed that the nurse was notified of the lab draw refusal. Review of behavioral monitoring from 03/05/25 through 04/02/25 revealed that Resident #9 exhibited no concerning behaviors. Review of lab result collected on 04/01/25 revealed that Resident #9 refused the blood draw. Review of care plan dated 04/03/25 revealed that Resident #9 had refused lab draws, exercising her right to make decisions. Interventions include providing encouragement as needed, enlisting the resident's preferences, and re-approaching later if necessary. Interview on 04/02/25 at 2:13 P.M. with the infection preventionist #200 confirmed that the resident has a standing order for as-needed Antibiotics. This was ordered due to the presence of hardware in her right hip and femur. The infection preventionist was unaware whether this hardware was documented in her medical record or if antibiotic use related to dental visits had been included. Interview on 04/03/25 at 11:11 A.M. with the Minimum Data Set (MDS) 3.0 nurse #150 confirmed that Resident #9's care plan did not include refusals of lab work or the use of Antibiotics. Interview on 04/03/25 at 11:13 A.M. with the Social Worker (SW) #205 confirmed that, according to Resident #9 's laboratory reports, she frequently refuses blood draws. SW #205 denied knowledge of Resident #9's consistent refusal of lab work and confirmed it should be addressed in her care plan. Interview with MDS nurse #150 on 04/03/25 at 11:11 A.M. confirmed that Resident #9 does not have a care plan addressing mobility or infection risks related to the hardware in her right hip and femur. Based on medical record review, staff interview, and facility policy review, the facility failed to initiate care plans as needed. This affected five residents (#44, #67, #65, #9, and #4) of 18 resident care plans reviewed. The census was 68. Findings Include: 1. Resident #44 was admitted to the facility on [DATE]. Her diagnoses were Type II Diabetes Mellitus, functional urinary incontinence, blepharitis, hypothyroidism, hyperlipidemia, osteoporosis, vitamin D deficiency, anemia, dysphagia, venous insufficiency, kyphosis, hypo-osmolality and hyponatremia, anxiety disorder, cognitive communication deficit, lack of coordination, depression, shortness of breath, diarrhea, and GERD. Review of her minimum data set (MDS) assessment, dated 02/20/25, revealed she was cognitively intact. Review of Resident #44 physician orders, dated 12/24/24, revealed an order for Amoxicillin (antibiotic) 500 milligrams (mg), one time a day for prophylactic regarding osteonecrosis of jaw. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 4 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 - Some Review of Resident #44 current care plans found no care plan for the use of an antibiotic and/or treatment for an infection to her jaw. Interview with Licensed Practical Nurse (LPN) #403 on 04/03/25 at 9:00 A.M. confirmed he is not aware of any antibiotic care plan for Resident #44. He confirmed the care plan would be in the electronic medical record if there was one. Interview with Assistant Director of Nursing (ADON) #200 on 04/03/25 at 3:01 P.M. confirmed Resident #44 did not have an antibiotic care plan, but should have it. 2. Resident #67 was admitted to the facility on [DATE]. Her diagnoses were hemiparesis and hemiplegia, acromegaly and pituitary gigantism, morbid obesity, hyperlipidemia, hypertension, dysphagia, muscle weakness, need for assistance with personal care, dysarthria, and edema. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact. Review of Resident #67's current physician orders found the following pain medications ordered: Tramadol 50 mg every six hours as needed for pain, which was started on 10/31/24; Tramadol (opioid) 100 mg every 24 hours as needed for severe pain, which was started on 03/18/25, Acetaminophen (analgesic) 500 mg, two tabs every six hours as needed for pain, which was started on 11/08/24, and Ibuprofen (nonsteroidal anti inflammatory) 400 mg every six hours as needed for pain, which was started on 11/04/24. Review of Resident #67 current care plans found no care plan for pain or the use of pain medication. Interview with LPN #403 on 04/03/25 at 9:00 A.M. confirmed a care plan would be in the electronic medical record if there was one. Interview with LPN #150 on 04/03/25 at 10:38 A.M. confirmed Resident #67 had no care plan for pain; they added it today. He confirmed there should have been a care plan for pain or pain management. Review of facility Pain Management policy, dated 09/10/24, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 5 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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** Medical record review revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included, major depressive disorder, polyoteoarthritis and hypertension. Review of the comprehensive Minimum Data Set assessment, dated 03/25/25, revealed the resident's cognition was intact. Residents Affected - Some Review of a physician order, dated 03/20/24, revealed Resident #4 was ordered Nortriptyline (an antidepressant medication) three capsules daily at bed time for neck pain. Review of the Resident #4's Medication Administration Record (MAR) revealed the resident received Nortriptyline, as ordered, beginning 03/20/24. Review of Resident #4's medical record revealed there was no monitoring the resident for depressed and withdrawn behaviors. Interview on 04/03/25 at 3:09 P.M. with LPN #50 confirmed behavior monitoring was not being tracked and/or documented for Resident 's depression and behaviors. 3. Review of Resident #40's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included depressive disorder, cognitive communication deficit and vascular dementia. Review of Resident #40's Minimum Data assessment dated [DATE] revealed that she received antidepressant medication. Review of Resident #40's physician' orders dated 12/19/24 revealed that she received an antidepressant medication, Sertraline HCL, 100 milligrams in the quantity of one tablet by mouth once daily. Review of Resident #40's Treatment Administration Record (TAR) revealed there was no documentation present for monitoring for side effects of an antidepressant medication and there was no documentation present for monitoring for signs and symptoms of depression. Review of Resident #40's tasks in the medical record revealed that they were silent for monitoring for side effects of an antidepressant medication and silent for monitoring for signs and symptoms of depression. Review of Resident #40 care plan dated 03/12/21 revealed that she was at risk for the potential for a therapeutic regiment due to her antidepressant medication. Her goal was listed as to be free from discomfort for adverse reactions related to her antidepressant therapy through the review date. Her care plan goals included being monitored and documented for ongoing signs of depression and that she would be monitored for side effects and effectiveness of the medication and that these would be documented. Interview with Licensed Practical Nurse (LPN)# 160 on 04/03/25 at 1:36 P.M. revealed when a resident is on an antidepressant medication, nursing would monitor for signs of depression and signs and symptoms of side effects from the medication. Interview with Director of Nursing on 04/03/25 at 1:34 P.M. revealed that if a resident is on an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 6 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some antidepressant medication, nursing is expected to monitor for signs and symptoms of depression and side effects of the medication. Further interview revealed that these would be documented in the medical record under the tasks documentation in the medical record or in the TAR. Interview with LPN #150 on 04/03/25 at 2:37 P.M. confirmed that Resident #40's medical record did not contain documentation of the resident being monitored for signs and symptoms of depression and for side effects of her antidepressant medication since 12/01/24. 2. Review of the medical record for Resident #3, admitted on [DATE], revealed diagnoses of basal cell carcinoma of the skin, age-related osteoporosis, rheumatoid arthritis, bilateral arm pain, and a wedge compression fracture of T11-T12. Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 02/05/25, indicated that Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The health conditions section of the MDS indicated that the resident receives scheduled pain medication, as well as as-needed (PRN) medication and non-medication interventions for pain management. Review of the medication administration record for March 2025 revealed Resident #3 has an order for as needed Aspercreme Lidocaine 4% patch for pain, this medication was not utilized in March 2025. Review of the medication administration record for March 2025 revealed Resident #3 has an order for as needed acetaminophen 500 milligram (mg) capsule every four hours as needed for mild pain, this as needed medication was not utilized March 2025. Review of the medication administration record for March 2025 revealed Resident #3 received as needed Tramadol (narcotic) mg for pain it was administered on 03/04/25 for pain at three out of 10, on 03/09/25 for pain at three out of 10, On 03/13/25 pain at two out of 10, 03/17/25 for pain at three out of 10, and on 03/22/25 for pain at three out of 10. Review of the medication administration record for March 2025 revealed Resident #3 received scheduled Tramadol 50 mg at 8:00 A.M. on 03/05/25 for pain of 0/10, on 03/14/25 for pain at 0/10, and on 03/19/25 for pain at 0/10. Interview conducted on 04/02/25 at 2:33 PM with Registered Nurse #210, the nursing staff, confirmed that PRN pain medication is administered based on the resident's reported pain level and location. The resident is asked to rate their pain, and the appropriate medication is administered based on the pain level. Lower-strength medications are given for pain levels of one to five, while higher-strength options are given for pain levels 6-10. If pain medication is administered outside of these prescribed parameters, a progress note is required to explain the deviation. RN #210 further confirmed that medication selection is influenced by the location of the pain and that clear guidelines should be established for selecting the appropriate medication based on these factors. Interview with Registered Nurse #210 on 04/03/25 at 10:14 AM revealed that Resident #3 does not have specific parameters for when pain medication should be administered. It was noted that on some occasions, narcotic medications are administered even when the pain level is reported as low or 0/10, as reflected in the medical record. She confirmed that the resident typically follows a scheduled regimen for pain medication, often requesting Tramadol at night, though no formal pain parameters are currently in place for the administration of these medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 7 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and facility policy review, the facility failed to have proper pain parameters for residents using as needed pain medication. This affected two (Residents #67 and #3) of three residents reviewed for pain management. Also, the facility failed to monitor medication side effects for residents prescribed psychotropic medications. This affected two (Resident #4 and #40) of five residents reviewed for unnecessary medications. The census was 68. Residents Affected - Some Findings Include: Resident #67 was admitted to the facility on [DATE]. Her diagnoses were hemiparesis and hemiplegia, acromegaly and pituitary gigantism, morbid obesity, hyperlipidemia, hypertension, dysphagia, muscle weakness, need for assistance with personal care, dysarthria, and edema. Review of her minimum data set (MDS) assessment, dated 02/13/25, revealed she was cognitively intact. Review of Resident #67's current physician orders found the following as needed pain medications ordered: Tramadol (opioid) 50 milligrams (mg) every six hours as needed for pain, which was started on 10/31/24; Tramadol 100 mg every 24 hours as needed for severe pain, which was started on 03/18/25, Acetaminophen (analgesic) 500 mg, two tabs every six hours as needed for pain, which was started on 11/08/24, and Ibuprofen ( non steroidal anti inflammatory) 400 mg every six hours as needed for pain, which was started on 11/04/24. Review of these medications found there were no parameters or guidelines as to when each medication should be administered. Review of Resident #67's medication administration records, dated November 2024 to March 2025, revealed the following as needed pain medications that were ordered, administered, and the pain levels that were documented for each administration in totality from November 2024 to March 2025: Acetaminophen had 22 total administrations for pain levels that varied between one and seven; Ibuprofen had 116 administrations for pain levels that varied between zero and six; Tramadol 50 mg had 81 administrations for pain levels that varied between zero to ten, and Tramadol 100 mg was administered two times for pain levels between two and six. Ibuprofen was administered a total of five times for a pain level of zero, and Tramadol 50 mg was administered a total of two times for a pain level of zero. Review of Resident #67's care plans revealed no care plan regarding the use of pain medication or pain management. This also included no parameters as to when each pain medication should be administered. Review of Resident #67's progress notes, dated November 2024 to March 2025, revealed no progress notes to justify the reasons as to why as needed pain medication was given based on their pain levels, and no justification as to why as needed pain medication was given for a pain level of zero. Interviews with Registered Nurse (RN) #302 and RN #210 on 04/02/25 at 2:05 P.M. and 2:10 P.M. stated as needed pain medication is given based on the pain level and location of pain. They stated they will ask the resident what their pain level is, and then ask the resident which pain medication they would like to have. Typically, they will provide lower strength pain medication (ibuprofen or acetaminophen) for pain levels of one to five, then higher strength pain medication (Tramadol) for pain levels of six to ten. If they provide pain medication outside of those parameters or guidelines, there will be a progress note to support it. But, they confirmed there should be specific parameters for which pain medication to give, when there is more than one as needed pain medication prescribed. Review of facility Pain Management policy, dated 09/10/24, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 8 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (IDT), may necessitate gathering the following information, as applicable to the resident: current prescribed and pain medications dosage and frequency. Factors influencing the course of treatments include: the cause, location, and severity of resident's pain, the resident's current medical condition, the resident's current medications, the resident's desired level of relief and tolerance for adverse consequences, potential benefits, risks, and consequences of medications, and available treatment options. Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has a potential for pain. The following are general principles the facility will utilize in prescribing analgesics: use lower doses of medication initially and titrate slowly upward until comfort is achieved. Event ID: Facility ID: 366135 If continuation sheet Page 9 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure medications were properly stored to ensure medications did not exceed the expiration date on stock medication supplies. This affected 28 residents living on the first and second floor. The facility census was 68. Findings include: Observation of the second floor medication room on [DATE] at 1:35 P.M. revealed a single medication cabinet in which nursing staff stores over the counter medication for residents of the first and second floor. The cabinet also stores medications residents have in possession prior to admission, to be held until the residents are discharged . The cabinet had various scattered medications and empty boxes. Pulls of medication revealed Ferrous Gluconate (iron replacement) 240 mg with an expiration date of 05/2024. Additionally pulled from the cabinet were Systane drops (ophthalmic lubricant) with an expiration date of 11/24. Interview on [DATE] at 1:37 P.M. with Licensed Practical Nurse (LPN) #160 confirmed the two medications were expired and they should be disposed of. A medication storage policy was requested from the facility however there was none provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 10 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2. Observations on a tour of the facility's kitchen on 03/31/25 between 8:35 A.M. and 8:59 A.M. revealed a red and black substance inside the white plastic backboard of ice machine which was easily removed with a cleansing towel. A crate of bananas on floor of the dry storage room. A fuzzy gray and brown substance on the walk-in refrigerator's ceiling, near the internal fans. In the walk-in freezer there were opened and undated packages of crinkle carrots. There was also an unlabeled and undated cup of a brown substance. On the freezer floor there were two crates of bread loaves, a package of fire roasted sweet potatoes and a bag of tater tots. In the walk-in freezer ceiling there were icicles present, and evidence of ice formed on one package of frozen cheese manicotti. On 03/31/25 at 8:37 A.M. [NAME] #374 revealed that she opened the undated frozen carrots but could not recall the date that she opened them. She stated that the brown substance was a chocolate milkshake but unsure when it was made. She also confirmed the food items sitting on the freezer floor. She acknowledged the ice on the cheese manicotti and added that ice should not be on the packaging. On 03/31/25 at 8:47 A.M. Dietary Aide #388 confirmed the presence of the red and black substance inside the ice machine that it is easily removed by wiping it. On 03/31/25 at 9:03 A.M. during an interview Dietary Manager confirmed the undated opened food in the freezer, the items found on floor and the presence of the icicles on the ceiling and dripping on to the manicotti box. Based on observations, staff interviews, review of facility policies and review of food safety guidelines recommended by the Centers for Disease Control and Prevention, the facility failed to serve and store food in a safe and sanitary manner. This had the potential to affect all 68 residents in the facility that ate food from the kitchen and 35 residents who ate in the dining room on 04/01/25 (Residents #58, #4, #53, #36, #29, #271, #60, #64, #45, #59, #39, #66, #68, #54, #56, #55, #57, #2, #27, #42, #12, #15, #25, #44, #51, #46, #50, #62, #67, #23, #34, #6, #16, #52, and #28) . The facility census was 68 residents. Findings include: 1. Observations on 04/01/25 at 12:17 P.M. in the dining room of the temperatures of the seafood salad on the buffet serving line revealed that the seafood salad was being stored on the buffet serving line was being held at a temperature on the buffet line from 49 to 51 degrees Fahrenheit. Director of Dietary Services #165 took the holding temperatures of the seafood salad on 04/01/25 at 12:17 P.M. in two locations of the container that held the seafood salad. The first temperature that registered in the seafood salad was 51 degrees Fahrenheit. The Director of Dietary Services #165 was observed stirring the seafood salad and obtained a second temperature from the middle of the seafood salad. The observed temperature that registered was 49 degrees Fahrenheit. Interview with the Director of Dietary Services #165 on 04/01/25 revealed that the seafood salad had been on the food service line since 11:45 A.M. Further interview on 04/02/25 at 9:55 A.M. revealed that the holding temperature should be at 40 degrees or lower for the seafood salad. Review of facility policy titled Food Safety Requirements dated 2023 revealed that foods and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 11 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 beverages shall be maintained at the proper temperature and out of the danger zone. Level of Harm - Minimal harm or potential for actual harm Review of the Centers for Disease Control and Prevention's website on Food Safety revealed that bacteria can multiply rapidly if it is in the danger zone between 40 and 140 degrees fahrenheit. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 12 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 - Few 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** Based on medical record review, staff interview, staff attestation statements and time clock record review, the facility failed to keep an accurate medical record for one resident. This affected one resident (Resident #5) and had the potential to affect 28 residents (Resident #37, #4, #65, #29, #66, #21, #45, #47, #171, #68, #39, #55, #54, #40, #59, #53, #26, #5, #69, #33, #22, #8, #64, #58, #38, #56, and Former Residents #200 and 201) that were residing on the first and second floors of the facility on 01/9/25. Findings include: Review of Resident #5's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN), gastroesophageal reflux disease (GERD), polyarthritis, major depressive disorder, primary osteoarthritis, chronic kidney disease (CKD), Vitamin B-12 deficiency, and Vitamin D deficiency. Review of Resident #5's physician orders revealed that effective on 03/01/24, she was prescribed Amlodipine Besylate 5 milligrams (mg) one tablet once daily for hypertension, Aspirin 81 mg one tablet once daily for prevention, Diltiazem 24 hour extended release 240 mg one capsule once daily for hypertension, Fluoxetine HCl 40 mg one capsule once daily for major depressive disorder, Omeprazole Delayed Release 20 mg one capsule once daily for GERD, Vitamin B-12 1000 micrograms (mcg) one tablet once daily for Vitamin B-12 deficiency, Vitamin D3 50 mcg one tablet once daily for Vitamin D3 deficiency, Carvedilol 12.5 mg one tablet twice daily for hypertension, Clonidine HCl 100 mg one tablet twice daily for hypertension, Hydralazine 100 mg one tablet twice daily for hypertension, Oysco 500 mg one tablet twice daily, and Tylenol Arthritis Extended Release 650 mg 1 tablet twice daily; Effective 08/21/24, she was prescribed Torsemide, a diuretic, 10 mg one tablet once daily for CKD; Effective 04/19/24, she was prescribed Losartan Potassium 50 mg one tablet once daily for hypertension. Review of Resident #5's Medication Administration Record (MAR) revealed that on 01/09/25, there was no evidence that the following medications had been administered in the morning: Amlodipine Besylate 5 mg one tablet, Aspirin 81 mg one tablet, Diltiazem 24 hour extended release 240 mg one capsule, Fluoxetine HCl 40 mg one capsule, Omeprazole Delayed Release 20 mg one capsule, Vitamin B-12 1000 mcg one tablet, Vitamin D3 50 mcg one tablet, Carvedilol 12.5 mg one tablet, Clonidine HCl 100 mg one tablet, Hydralazine 100 mg, Oysco 500 mg one tablet, and Tylenol Arthritis Extended Release 650 mg one tablet, Torsemide10 mg one tablet, and Losartan Potassium 50 mg one tablet. Review of Resident #5's medical record revealed that she had not had any adverse reactions as a result of the medication administration not being administered. Interview with Resident #5 on 04/03/25 at 9:45 A.M. revealed that she did not recall a time where she was not given her morning medications. Interview with the Director of Nursing on 04/03/25 at 9:30 A.M. revealed there was no evidence in the medical chart that the medications had been administered to Resident #5 on the morning of 01/09/25. Review of the time sheets for Licensed Practical Nurse (LPN) #170 for 01/09/25 revealed that she was on duty at the facility on 01/09/25 from 8:20 A.M. until 12:52 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366135 If continuation sheet Page 13 of 14 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 366135 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the attestation statements on 04/03/25 authored by Scheduler #175, Registered Nurse #155, and the Director of Nursing regarding the events of 01/09/25 revealed that on 01/09/25, LPN #170 was the nurse working on the first and second floors of the facility. She left the building on 01/09/25 at 12:52 P.M. after claiming she was too anxious to complete her shift. LPN #170 left the faciity on [DATE] without signing off the medication administration record in its entirety for Resident #5. RN #155, a member of the facility's nursing administration team, completed the duration of LPN #170's shift, and LPN #170 was reported to the nursing board for job abandonment. Event ID: Facility ID: 366135 If continuation sheet Page 14 of 14