Inspection·February 16, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a withdrawal record dated [DATE] revealed $52.59 was to be credited to Resident #35's care cost payments. Interview on [DATE] at 12:00 P.M. with BOM/HR #122 verified Resident #35 did not have his final resident funds disbursal completed timely after his death on [DATE]. BOM/HR #122 stated Resident #35 had an outstanding balance with the facility, so his funds were applied to that on [DATE]. Event ID: Facility ID: 366141 If continuation sheet Page 2 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interview the facility failed to complete a discharge summary as required. This affected one resident (#34) of one resident reviewed for discharge from the facility. The facility census was 36 residents. Findings include: Review of Resident #34's medical record revealed and admission date of 07/29/22 and diagnoses including chronic obstructive pulmonary disease, type two diabetes, alcoholic cirrhosis of liver with ascites, opioid abuse, hypertension, and unspecified intracranial injury without loss of consciousness. Review of completed physician's orders for Resident #34 revealed an order dated 12/07/22 for may discharge to [facility name] on 12/08/22. May send all medications with resident. Review of a discharge-return not anticipated minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 discharged to another nursing home on [DATE]. Resident #34 was cognitively intact and required supervision for most activities of daily living. Review of Resident #34's assessments revealed no discharge summary or recapitulation of stay. The last assessment completed was a skin assessment on 12/03/22. Review of progress notes revealed a note dated 12/08/22 that indicated Resident #34 discharged at this time and all belongings and medications were sent with Resident #34. The note did not state the location where Resident #34 discharged to. Review of the facility discharge list dated December 2022 revealed Resident #34 discharged from the facility on 12/09/22 to another facility. Disposition was listed as nursing facility to nursing facility transfer. Interview on 02/15/23 at 10:35 A.M. with Social Service Designee (SSD) #114 revealed Resident #34 wanted to go to another skilled nursing facility and that was where he discharged on 12/08/22. SSD #114 confirmed she did not complete a discharge summary or recapitulation for a resident when they went from this nursing facility to another nursing facility including for Resident #34 on 12/08/22. SSD #114 also verified there should have been a progress note stating where Resident #34 discharged to. SSD #114 provided the facsimile information between her and the receiving nursing facility where Resident #34 discharged to during the interview. Review of an electronic mail dated 11/28/22 revealed information was sent to another nursing facility regarding Resident #34, but this information did not include a recapitulation of stay or discharge summary. Review of the facility policy, Transfer or Discharge, Preparing a Resident For, dated December 2016, revealed nursing services was responsible for preparing the discharge summary and the post-discharge plan, completing discharge note in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 3 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, policy review and staff interview, the facility failed to ensure Resident #9 was assisted with Activities of Daily Living (ADL) including hygiene, dressing, and showers. The facility also failed to assist Resident #86 with denture care. This affected two residents (#9 and #86) of two residents reviewed for ADL assistance. The facility census was 36. Residents Affected - Few Findings include: 1. Review of Resident #9's medical record revealed an admission date of 07/15/14 with diagnoses including quadriplegia, chronic obstructive pulmonary disease, and diabetes mellitus. Review of Resident #9's Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 01/12/23 revealed the resident had an independent cognition level and required total staff assistance with ADL including dressing, personal hygiene, and toileting. Review of Resident #9's plan of care revealed a care plan for ADL assistance that indicated Resident #9 required total staff assistance with ADL due to weakness and quadriplegia. Further review of the medical record including the State Tested Nurse Aide (STNA) ADL Tasks for personal hygiene assistance provided from 01/15/23 to 02/15/23 revealed no evidence of any documentation of personal hygiene assistance provided from 01/15/23 to 01/31/23, 02/01/23 P.M., 02/02/23 P.M., 02/03/23 to 02/04/23, 02/06/23 P.M., 02/07/23 to 02/08/23, 02/09/23 A.M. and 02/10 to 02/13/23. Further review of the STNA ADL Tasks for dressing assistance provided from 01/15/23 to 02/15/23 revealed no evidence of any documentation for dressing assistance provided from 01/15/23 to 01/31/23, 02/01/23 P.M., 02/02/23 P.M., 02/03/23 to 02/04/23, 02/06/23 P.M., 02/07/23 to 02/08/23, 02/09/23 A.M. and 02/10/23 to 02/13/23. Further review of the STNA ADL tasks for toileting assistance provided from 01/15/23 to 02/15/23 revealed no evidence of any documentation for toileting assistance provided from 01/15/23 to 01/30/23, 01/31/23 PM, 02/01/23 P.M., 02/02/23 P.M., 02/03/23 A.M. and P.M., 02/04/23 A.M., 02/06/23 P.M., 02/07/23 to 02/08/23, 02/09/23 A.M. and 02/10/23 to 02/13/23. On 02/14/23 at 2:15 P.M. interview with the Director of Nursing verified no documentation of evidence of ADL assistance for Resident #9 including personal hygiene, dressing, and toileting assistance. 2. Review of Resident #86's record revealed an admission date of 01/24/23 and diagnoses including type two diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, schizophrenia, depression, migraine, and generalized anxiety. Review of Resident #86's physician's orders as of 02/15/23 revealed no orders for denture care. Review of Resident #86's MDS 3.0 assessments revealed the admission MDS dated [DATE] was still in progress as of 02/15/23. Review of Resident #86's assessments revealed an admission evaluation with baseline care plan dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 4 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm 01/25/23 that indicated Resident #86's prior level of functioning included needing some help from self-care and ambulation. Resident #86 had her own teeth in good/fair condition and dentures were marked as na. Resident #86's oral cavity was marked as moist and intact. Resident #86's admission performance indicated she required the assistance of one staff for personal hygiene. Residents Affected - Few Review of Resident #86's nurses' notes did not indicate routine denture care was being provided. Review of Resident #86's point of care charting for oral care/fingernails the last 30 days revealed oral care was signed off as being completed once a day on 01/25/23, 01/26/23, 01/27/23, and 01/29/23. No oral care was documented on 01/28/23, 01/30/23, 01/31/23, 02/01/23, 02/02/23, 02/03/23, 02/04/23, 02/05/23, 02/06/23, 02/07/23, 02/08/23, 02/09/23, 02/10/23, 02/11/23, 02/12/23, 02/13/23, 02/14/23, and 02/15/23. Review of Resident #86's care plans revealed no plans of care related to oral care. Interview on 02/13/23 at 7:02 P.M. with Resident #86 revealed her dentures were not being cleaned and she was not provided with denture cleaner to clean them herself. Resident #86 stated she told staff again (not identified) on 02/12/23. Interview on 02/16/23 at 8:25 A.M. with STNA #140 revealed Resident #86 took care of her own teeth and there was no shortage of oral care supplies at the facility. Interview on 02/16/23 at 8:28 A.M. with STNA #120 revealed Resident #86 had her natural teeth and staff would set her up for oral care. STNA #120 showed the surveyor oral supplies available on the 100/200 hall nurses' station supply room which appeared adequate. Interview on 02/16/23 at 9:00 A.M. with MDS/Licensed Practical Nurse (LPN) #111 revealed Resident #86 had her natural teeth. An observation was requested to observe Resident #86's teeth due to variance in interviews and record review. Observation of Resident #86 on 02/16/23 at 9:03 A.M. with MDS/LPN #111 and STNA #140 present revealed Resident #86 was up in bed. When asked about the status of her teeth, Resident #86 took out her bottom and top dentures and reiterated her dentures were not being cleaned. Resident #86's dentures were observed and did not appear clean during the observation. Follow-up interview on 02/16/23 at 9:03 A.M. with MDS/LPN #111 verified Resident #86 required oral care and would be provided with a denture cup. During an interview on 02/16/23 at 11:02 A.M. the DON was made aware of the lack of evidence Resident #86's oral care was being completed routinely as well as the inaccuracy of Resident #86's admission evaluation indicating she had natural teeth when in fact Resident #86 had full dentures. Review of the policy, Dentures, Cleaning and Storing, revised March 2018, revealed staff were to review the resident's care plan to assess for any special needs of the resident. Provide denture care before breakfast and at bedtime. The following information should be recorded in the resident's medical record: the date and time the denture care was performed (note A.M. and P.M. on the ADL record), who performed the denture care, all assessment data obtained concerning the resident's mouth and if the resident refused the treatment, the reason(s) why and the intervention taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 5 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to timely turn and reposition Resident #11 and failed to timely complete a Braden Scale for predicting pressure sore risk assessment. The facility also failed to ensure pressure ulcer wound assessments were timely and thoroughly completed for Resident #12. This affected two residents (#11 and #12) of two residents reviewed for pressure ulcers. The facility census was 36. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance of two staff for bed mobility. Review of the care plan dated 03/06/20 revealed Resident #11 had an alteration in skin integrity with the intervention to encourage to turn and reposition every two hours and as needed. Review of the Braden Scale for predicting pressure sore risk assessment dated [DATE] revealed Resident #11 was at a moderate risk for developing a pressure ulcer. The instructions on the assessment revealed to complete on admission, weekly for four weeks, and then quarterly thereafter. Review revealed no subsequent Braden Scale for predicting pressure sore risk assessments were completed. Review of physician orders dated 01/03/23 revealed the order to turn and reposition the resident every two hours. Review of the Weekly Wound Observation dated 02/09/23 revealed Resident #11 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed), located on the sacrum, acquired on 01/03/23, and measured 2.0 centimeters (cm) in length by 1.0 cm in width by 0 cm in depth. The wound had a moderate amount of serosanguineous drainage (thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells). The wound nurse practitioner (NP) progress note dated 02/09/23 revealed the wound bed had slough and pink tissue. The peri-wound (area surrounding the wound) was intact. There was no odor or signs of infection. During observation on 02/15/23 at 9:14 A.M., Resident #11 was observed lying on her back in bed. During observation on 02/15/23 at 10:52 A.M., the resident continued to be lying on her back in bed with her eyes closed and appeared to be sleeping. During observation on 02/15/23 at 11:44 A.M., the resident remained in the same position, lying on her back in bed. During interview on 02/15/23 at 11:46 A.M., Licensed Practical Nurse (LPN) #121 confirmed Resident #11 was lying on her back and had not been repositioned every two hours as ordered by the physician. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 6 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0686 Level of Harm - Minimal harm or potential for actual harm diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, asthma, pulmonary hypertension, necrotizing fasciitis (flesh eating disease), Stage IV( full-thickness skin loss extending in to the subcutaneous tissue) pressure ulcer to the sacrum, congestive heart failure, lymphedema, peripheral neuropathy, depression, intestinal malabsorption, hypertension, neuromuscular dysfunction of the bladder, spondylosis, osteoarthritis, and COVID-19. Residents Affected - Few Review of the admission skin assessment dated [DATE] revealed Resident #12 was admitted to the facility with a Stage IV pressure ulcer to the sacrum which measured 6.0 centimeters (cm) in length by 3.0 cm in width by 0.5 cm in depth. Review of the admission Braden Scale for predicting pressure sore risk assessment revealed Resident #12 was at moderate risk for developing pressure ulcers. Review of the physician's orders revealed Resident #12 had an order dated 11/18/22 to cleanse her sacral wound with Dakin's solution (antimicrobial cleanser), lightly pack the wound with Dakin's-soaked gauze, lay an abdominal dressing on the wound with no tape, change the dressing twice daily and as needed, an order dated 09/29/22 for a low air loss mattress, and she was on a vegan diet. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #12 had intact cognition, required extensive assistance of two staff members for bed mobility and total assistance of two staff member for transfers. Further review revealed she had a Foley catheter, was incontinent of bowel and was admitted with a Stage IV pressure ulcer. Review of the weekly wound observations dated 10/06/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12, and the wound had slough and necrotic tissue present. There was no documented evidence the resident refused measurements. Review of the weekly skin observations dated 10/16/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the surgical wound care service notes dated 10/20/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the weekly skin assessment dated [DATE] revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the surgical wound care service notes dated 10/27/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the nurses' notes dated 10/30/22 revealed Resident #12 was sent out to the hospital for being unresponsive. She was readmitted on [DATE]. Review of the Admission/readmission Skin Evaluation dated 11/03/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 7 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the surgical wound care service notes dated 11/17/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the weekly skin observations dated 11/26/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the weekly skin observations dated 12/04/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the surgical wound care service notes dated 12/08/22 revealed there were no measurements of the Stage IV sacral pressure injury for Resident #12. There was no documented evidence the resident refused measurements. Review of the nurses' notes dated 12/15/22 revealed Resident #12 had been sent out to the hospital for wheezing and crackles in bilateral lung fields and was sent back to the facility the same day. Review of the plan of care dated 12/29/22 revealed Resident #12 was noncompliant with care and treatment as ordered by physician. She refuses to be turned and repositioned, declined to be out of bed most days, declined care, medications, and treatment changes. She declined protein supplements and dietary interventions to meet protein needs in the diet to aid in wound healing. On 02/16/23 at 11:30 A.M. The Director of Nursing indicated she has only been employed at the facility and doing the wound grids since 12/19/22. At 1:12 P.M. she verified the wound assessment for the sacral pressure injury for Resident #12 had not been completed weekly as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 8 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure fall interventions were in place for Resident #11. This affected one resident (#11) of one resident reviewed for accidents. The facility census was 36. Findings include: Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and required extensive assistance of two staff for bed mobility and was totally dependent on the staff for transfers. The resident had a history of falls. Review of the care plan dated 03/06/20 revealed Resident #11 was at risk for falls related to decreased physical condition, incontinence, medication, and impaired cognition. Interventions included for the bed to be in the lowest position while occupied, and for a soft fall mat at the bedside. Review of a nursing progress note dated 11/22/22 revealed Resident #11 was noted on the floor, next to the bed. Assessment revealed no injuries, and the neurological checks were within normal limits. The new intervention was for a perimeter mattress to be used to alert the resident of the bed edges. Review of the fall risk assessment dated [DATE] revealed the resident was at a high risk for falls. Review of physician orders dated 11/29/22 revealed the order for a soft fall mat at bedside. During observation on 02/14/23 at 10:18 A.M., Resident #11 was observed lying on her back in bed. The bed was not in the lowest position, nor was there a fall mat located on the floor beside her bed as ordered. During interview on 02/14/23 at 10:19 A.M., State-Tested Nursing Assistant (STNA) #140 confirmed the bed was not in the lowest position and there was no fall mat on the floor. During interview on 02/14/23 at 10:20 A.M., the Director of Nursing (DON) confirmed Resident #11 should have a fall mat on her floor, beside her bed, and the bed should be in the lowest position when occupied by the resident. Review of the facility's policy, Managing Falls and Fall Risk, dated March 2018, revealed the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 9 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and interview, the facility failed to ensure Resident #11 received proper incontinence care to decrease the resident's risk of developing a urinary tract infection. The facility also failed to provide timely catheter care to Resident #86. This affected two (Resident #11 and #86) of two residents reviewed for incontinence/urinary tract infection. The facility identified 22 residents who were occasionally or frequently incontinent of bladder and four residents who had urinary catheters. The facility census was 36. Findings include: 1. Medical record review revealed Resident #11 was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, morbid obesity, chronic kidney disease, cerebral infarction, hemiplegia and hemiparesis affecting right side, spinal stenosis, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 11/01/22, revealed Resident #11 was severely cognitively impaired and required extensive assistance of two staff for toileting and was totally dependent on two staff for bathing and personal hygiene. The resident was always incontinent of bowel and bladder. Review of the Care Plan, dated 03/06/20, revealed the resident experiences bladder incontinence and her toileting needs will be met by staff to prevent infection with the intervention to provide care after each episode of incontinence. During observation of incontinence care on 02/14/23 at 11:13 A.M. State Tested Nursing Assistants (STNA) #120 and #140 provided incontinence care to Resident #11 prior to wound care. During the procedure, STNA #140 first proceeded to clean the resident's groin area and inner thighs. Next, using the same washcloth, STNA #140 proceeded to separate the labia and wipe the urethral area. During interview on 02/14/23 at 11:25 A.M. Licensed Practical Nurse (LPN) #115 confirmed STNA #140 improperly performed Resident #11's incontinence care by not using a clean washcloth before proceeding to clean the inner labial areas. Review of the facility's policy, Perineal Care, dated February 2018 revealed for a female resident to wash the perineal area, wiping from front to back. Separate the labia and wash area downward from front to back. Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same direction, using fresh water and a clean wash 2. Review of Resident #86's record revealed an admission date of 01/24/23 and diagnoses including type two diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, morbid obesity, schizophrenia, depression, migraine and generalized anxiety. Review of Resident #86's physician's orders as of 02/15/23 revealed no orders for catheter care. Review of Resident #86's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for January 2023 and February 2023 revealed no orders for catheter care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 10 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #86's minimum data set (MDS) 3.0 assessments revealed the admission MDS dated [DATE] was still in progress as of 02/15/23. Review of Resident #86's assessments revealed an admission evaluation with baseline care plan dated 01/25/23. Resident #86 was incontinent of bladder and used adult briefs. Resident #86 did not use a catheter and was incontinent of stool. Resident #86's admission performance indicated she required the assistance of two staff for toileting. Review of a nurses' note on 01/29/23 revealed Resident #86 had a new urinary catheter placed. Review of a nurse's note on 02/06/23 revealed Resident #86's urinary catheter was leaking and a new catheter was placed. Review of Resident #86's nurses' notes did not indicate routine catheter care was being provided. Review of Resident #86's point of care charting for catheter care for the last 30 days revealed catheter care was signed off as being completed only once a day on 01/31/23, 02/02/23, 02/04/23, 02/05/23, 02/06/23, 02/07/23, 02/08/23, 02/11/23, 02/12/23, 02/13/23 and 02/15/23. No catheter care was documented on 01/29/23, 01/30/23, 02/01/23, 02/03/23, 02/09/23, 02/10/23 and 02/14/23. Review of Resident #86's care plans revealed a plan of care dated 01/29/23 for potential for complications related to use of catheter in place due to neurogenic bladder. Interventions listed included provide catheter care every shift and as needed. Interview on 02/16/23 at 8:28 A.M. with State Tested Nursing Assistant (STNA) #120 revealed Resident #86 had a urinary catheter and catheter care was provided every time Resident #86 got into bed, every time Resident #86 got out of bed and if Resident #86 was incontinent of stool. STNA #120 indicated there were not specific times or frequency for the catheter care to be provided. Interview on 02/16/23 at 8:54 A.M. with Resident #86 indicated catheter care was done daily but not on each shift. Interview on 02/16/23 at 9:00 A.M. with Minimum Data Set (MDS)/Licensed Practical Nurse (LPN) #111 revealed Resident #86 had a urinary catheter and catheter care was to be provided each shift which was three times daily and as needed. MDS/LPN #111 reviewed Resident #86's record with the surveyor and verified no physician's order was available regarding Resident #86's urinary catheter. MDS/LPN #111 indicated catheter care was on the STNA point-of-care charting and this was also reviewed during the interview. MDS/LPN #111 verified the STNA point-of-care charting observed did not reflect Resident #86 had catheter care provided three times a day or on a consistent basis. During an interview on 02/16/23 at 11:02 A.M. the Director of Nursing (DON) was made aware of the lack of evidence Resident #86's catheter care was being completed routinely and was also notified there was no physician's order for Resident #86's urinary catheter. Review of the policy, Catheter Care, Urinary, revised September 2014 revealed staff were to review the resident's care plan to assess for any special needs of the resident. Empty the drainage collection bag at least every eight hours. The following information should be recorded in the resident's medical record: the date and time catheter care was given, who provided the catheter care, how the resident tolerated the procedures, if the resident refused the procedure, the reasons why and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 11 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0690 intervention taken. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 12 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 - Some 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 medical record review, Medscape online medication review, policy review, and staff interview the facility failed to ensure appropriate diagnosis for use of antipsychotic medications for Residents #11 and #32. The facility also failed to ensure appropriate assessments were completed for use of antipsychotic medications for Resident #32. The facility also failed to ensure behavior monitoring was completed for Residents #9, #11, #31 and #32 who were receiving psychotropic medications. In addition, the facility failed to ensure non-pharmacological interventions were attempted for Resident #11 prior to the administration of anti-anxiety medications. This affected four residents (#9, #11, #31 and #32) of five residents reviewed for medication use. The facility census was 36. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 11/09/22 with diagnoses including dementia, bipolar disorder, and anxiety. Review of the current physician's orders revealed on 01/24/23 Resident #32 was prescribed Fanapt (antipsychotic medication) two milligrams (mg) twice daily for bipolar disorder. Review of Medscape online application revealed the only indication for Fanapt use was for treatment of schizophrenia. Review of assessments for Resident #32 revealed no evidence of any Abnormal Involuntary Movement Scale (AIMS) completed prior to the use of antipsychotic medications. Further review of the medical record including the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no evidence of resident specific behavior monitoring or medication side effects monitoring were completed. Review of Resident #32's plan of care revealed care plans in place for the use of psychotropic medications and mood and behaviors which identified staff were to monitor the resident for behaviors and medication side effects and track on the monthly mood and behavior tracker. Interview with the Director of Nursing (DON) on 02/15/23 at 10:15 A.M. revealed behavior monitoring and medication side effect monitoring are recorded in the MARs and TARs. Interview with the DON on 02/15/23 at 1:30 P.M. verified Resident #32 did not have an appropriate diagnosis for use of Fanapt, no AIMS assessment had been completed with the use of an antipsychotic medication, and resident behaviors and medication side effects were not monitored. 2. Review of Resident #9's medical record revealed an admission date of 07/15/14 with diagnoses including schizophrenia, bipolar disorder, and anxiety. Further review of the medical record including current physician's orders revealed the use of Cymbalta (antidepressant) 60 mg twice daily, Seroquel (antipsychotic) 25 mg twice daily, and Xanax (anti-anxiety) 0.125 mg four times daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 13 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 - Some Further review of the medical record including MAR and TAR revealed no evidence of any resident behavior monitoring or medication side effect monitoring was completed. Review of Resident #9's plan of care revealed care plans in place for the use of psychotropic medications and mood and behaviors which identified staff were to monitor the resident for behaviors and medication side effects and track on the monthly mood and behavior tracker. Interview with the DON on 02/15/23 at 10:50 A.M. revealed behavior monitoring and medication side effect monitoring are recorded in the MARs and TARs. Interview with the DON on 02/15/23 at 1:30 P.M. verified no evidence of Resident #9's behaviors and medication side effects being monitored. 4. Review of the medical record for Resident #31 revealed an admission date of 10/27/22 with diagnoses including congestive heart failure, cirrhosis of the liver, alcohol abuse with alcohol-induced anxiety, agoraphobia, and major depressive disorder. Review of the MDS 3.0 assessment, dated 01/17/23, indicated Resident #31 had intact cognition. The MDS 3.0 assessment indicated the resident did not have any hallucinations, delusions, or rejection of care. Review of the care plan revealed Resident #31 had a potential for adverse side effects of psychoactive drug use. Interventions included to observe and document any abnormal behavior/moods and to document side effects of medication. Review of a physician order, dated 11/17/22, revealed the order for Mirtazapine 15 mg (antidepressant) one tablet every night for major depressive disorder. Review of the MAR, dated January 2023 and February 2023, revealed behaviors were not monitored with the administration of a psychoactive medication. During interview on 02/15/23 at 4:40 P.M., the DON verified Resident #31 was receiving Mirtazapine for depression, and there was no evidence of behavioral monitoring. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including diabetes, chronic obstructive pulmonary disease, chronic respiratory failure, chronic kidney disease, cerebral infarction, hemiplegia affecting the right side, depression, spinal stenosis, anxiety disorder, Alzheimer's disease, vitamin D deficiency, hyperlipemia, glaucoma, nondisplaced spiral fracture of the right femur, and congestive heart failure. Review of the physician's orders revealed Resident #11 had an order for Seroquel (antipsychotic medication) 25 mg at bedtime for yelling out, threatening others, hallucinations related to depression, and anxiety disorder dated 01/23/23; lorazepam (antianxiety) 0.5 mg every four hours as needed for 60 days for anxiety dated 01/24/23; and buspirone (antianxiety) 10 mg three times daily for anxiety. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severely impaired cognition and had disorganized thinking but no documentation of psychosis, hallucination, or delusions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 14 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 - Some Review of the plan of care dated 12/25/20 revealed Resident #11 could have an alteration in behaviors especially during times of being really confused, delusional activity and altercations with staff and/or other residents. Further review of the plan of care dated 01/20/20 revealed Resident #11 had mood patterns related to temperament at times. She could call staff names during care and confusing events, refuse care and treatment, decline staff enter her room, could be delusional at times, physically and verbally aggressive with staff, and would decline medication. Review of the progress notes from 12/01/22 to 12/31/22 revealed no documented evidence of behavior monitoring or non-pharmacological interventions attempted prior to the administration of her as needed lorazepam 0.5 mg on 12/02/22 at 4:03 P.M., 12/02/22 at 8:03 P.M., 12/04/22 at 12:41 P.M., 12/05/22 at 12:43 P.M., 12/06/22 1:18 P.M., 12/10/22 at 8:10 P.M., 12/11/22 at 8:55 P.M., 12/16/22 at 3:29 P.M., 12/19/22 at 8:19 P.M., 12/20/22 at 7:58 P.M., 12/21/22 at 11:18 P.M., and 12/24/22 at 6:57 P.M. Review of the December 2022 MAR revealed Resident #11 was administered lorazepam 0.5 mg on 12/02/22 at 4:03 P.M., 12/02/22 at 8:03 P.M., 12/04/22 at 12:41 P.M., 12/05/22 at 12:43 P.M., 12/06/22 1:18 P.M., 12/10/22 at 8:10 P.M., 12/11/22 at 8:55 P.M., 12/16/22 at 3:29 P.M., 12/19/22 at 8:19 P.M., 12/20/22 at 7:58 P.M., 12/21/22 at 11:18 P.M. and 12/24/22 at 6:57 P.M. with no non-pharmacological interventions attempted prior to the administration. Review of the progress notes from 01/01/23 to 01/31/23 revealed no documented evidence of behavior monitoring or non-pharmacological interventions attempted prior to the administration of her as needed lorazepam 0.5 mg on 01/13/23 at 8:05 P.M., 01/16/23 at 7:58 P.M., 01/29/23 9:19 A.M., 01/31/23 at 2:18 P.M. and at 7:20 P.M. Review of the January 2023 MAR revealed Resident #11 was administered lorazepam 0.5 mg on 01/13/23 at 8:05 P.M., 01/16/23 at 7:58 P.M., 01/29/23 9:19 A.M., 01/31/23 at 2:18 P.M. and at 7:20 P.M. with no documented evidence non-pharmacological interventions were attempted prior to the administration. Review of the progress notes from 02/01/23 to 02/16/23 revealed no documented evidence of behavior monitoring or non-pharmacological interventions attempted prior to the administration of her as needed lorazepam 0.5 mg on 02/01/23 8:36 P.M., 02/02/23 at 10:38 A.M., 02/05/23 at 7:22 A.M., 02/06/23 at 11:28 A.M., 02/13/23 at 8:28 A.M., 2:46 P.M. and 7:59 P.M. Review of the February 2023 MAR revealed Resident #11 was administered lorazepam 0.5 mg on 02/01/23 8:36 P.M., 02/02/23 at 10:38 A.M., 02/05/23 at 7:22 A.M., 02/06/23 at 11:28 A.M., 02/13/23 at 8:28 A.M., 2:46 P.M. and 7:59 P.M. with no non-pharmacological interventions attempted prior to the administration. On 02/14/23 at 11:48 A.M. an interview with the DON revealed all behavior documentation was completed in the progress notes and nowhere else. She also indicated all non-pharmacological interventions were documented on the MARs. On 02/16/23 at 7:34 A.M. an interview with the DON verified there were no behaviors documented in the progress notes for Resident #11 prior to administering lorazepam 0.5 mg. She also verified there were no non-pharmacological interventions attempted prior to the administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 15 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 02/16/23 at 12:27 P.M. Social Service Director #114 indicated Resident #11 was on Namenda and Aricept; however, when she started on hospice those medications were not on the recommend medication list for hospice. Namenda and Aricept were discontinued; her behaviors increased, so the physician placed her Seroquel for the behaviors. Review of the facility policy titled, Tapering Medication and Gradual Drug Dose Reduction, dated 04/07, revealed residents who used antipsychotic drugs should receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Pertinent behavioral interventions would also be attempted. Behavioral interventions referred to non-pharmacological attempts to influence an individual's behavior, including environmental alterations and staff approaches to care. Event ID: Facility ID: 366141 If continuation sheet Page 16 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and menu spreadsheet review, the facility failed to follow the menu's production spreadsheet as written. This affected one resident (Resident #17) of five residents receiving a pureed diet. The facility census was 36 residents. Findings include: Review of a menu for the week of 02/13/23 revealed the lunch meal for Tuesday 02/14/23 was roast pork loin, homestyle baked beans, California blend vegetables, pineapple upside-down cake and 2% milk. Reviewed of a production sheet for the lunch meal on Tuesday 02/14/23 revealed residents on a pureed diet were to receive a #8 scoop of pureed carrots, a #10 scoop of pureed pork loin, a #8 scoop of pureed baked beans and a #12 scoop of pureed pineapple upside-down cake. Observation on 02/14/23 at 11:50 A.M. with [NAME] #126 revealed foods to be served for the lunch meal on the steamtable included pureed baked beans, pureed carrots, mashed potatoes and pureed scrambled eggs which was a substitute for pureed pork loin. Desserts were portioned in bowls off of the steamtable. Trayline began at 12:30 P.M. The 200 unit trays were completed at 12:33 P.M.; the 100 unit trays were done at 12:42 P.M. and the dining room residents were finished being served at 12:55 P.M. The meal cart for residents that required feeding assistance began at 12:55 P.M. During the plating for these meals, [NAME] #126 ran out of pureed carrots leaving Resident #17 with a half #8 scoop of pureed carrots. Interview with [NAME] #126 during the observation revealed she thought it was a full scoop. The meal cart left the kitchen at 1:14 P.M., was on the unit at 1:15 P.M. and staff began to pass trays at 1:16 P.M. On 02/14/23 at 1:16 P.M. Dietary Manager (DM) #106 was requested to observe Resident #17's tray prior to it being passed. DM #106 took off the lid on Resident #17's tray and the plate contained a half #8 scoop of pureed carrots. DM #106 verified Resident #17 was not served the correct amount of pureed carrots at the time of observation and stated the cook normally prepared more than enough of the pureed foods to serve the correct amounts per the production sheets. Review of a diet list as of 02/14/23 revealed five residents (Residents #4, #13, #17, #18 and #85) received a pureed diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 17 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and menu review, the facility failed to ensure food was palatable. This affected 35 residents receiving food from the kitchen as Resident #23 was ordered nothing-by-mouth. The facility census was 36 residents. Residents Affected - Many Findings include: Review of a menu for the week of 02/13/23 revealed the lunch meal for Tuesday 02/14/23 was roast pork loin, homestyle baked beans, California blend vegetables, pineapple upside-down cake and 2% milk. Observation on 02/14/23 at 11:50 A.M. with [NAME] #126 revealed foods to be served for the lunch meal on the steamtable were temped using the facility's self-calibrating thermometer. Temperatures were as follows: pork roast, 195 degrees Fahrenheit (F); California blend vegetables, 204 degrees F; baked beans, 200 degrees F; mashed potatoes, 197 degrees F and gravy, 191 degrees F. Desserts were portioned in bowls off of the steamtable. Trayline began at 12:30 P.M. The 200 unit trays were completed at 12:33 P.M.; the 100 unit trays were done at 12:42 P.M. and the dining room residents were finished being served at 12:55 P.M. The meal cart for residents that required feeding assistance began at 12:55 P.M. and a test tray was requested to be made and placed on this cart. The test tray was made at 1:14 P.M. and the meal cart left the kitchen at 1:14 P.M The meal cart was on the unit at 1:15 P.M. and staff began to pass trays at 1:16 P.M. The test tray was sampled with Dietary Manager (DM) #106 at 1:30 P.M. using the facility's self-calibrating thermometer and the temperatures of the foods to be tested included milk, 48 degrees F; juice, 46 degrees F; pork, 138.7 degrees F; California blend vegetables, 138 degrees F and baked beans, 141.6 degrees F. The vegetables were overcooked, mushy and broken down. The pork was dry and hard to chew. Interview with DM #106 during the observation verified the vegetables and pork were not palatable as food had been held on the steamtable an extended period of time and the quality had deteriorated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 18 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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. Based on medical record review and staff interview, the facility failed to ensure meal intake amounts and meal assistance service was completely and accurately documented in the medical records for Resident #9. This affected one resident (Resident #9) of three residents reviewed for nutrition. The facility census was 36. Findings include: Review of Resident #9's medical record revealed an admission date of 07/15/14 with diagnoses that included quadriplegia, chronic obstructive pulmonary disease and diabetes mellitus. Review of Resident #9's Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 01/12/23 revealed the resident had an independent cognition level and required total staff assistance with activity of daily living (ADL) for eating. Review of Resident #9's plan of care reveled a care plan for ADL assistance that indicated Resident #9 required total staff assistance with ADLs due to weakness and quadriplegia. Further review of Resident #9's plan of care revealed a nutritional risk care plan which indicated staff were to assist with meals by feeding the resident and are to monitor percentage of meal intakes of each meal. Review of the medical record including the State Tested Nurse Aide (STNA) ADL Tasks for meal assistance from 01/15/23 to 02/15/23 revealed documentation of assistance with eating provided only on 01/30/23 lunch, 01/31/23 dinner, 02/04/23 dinner and 02/05/23 dinner. Further review of the STNA ADL Tasks for meal intake monitoring from 01/15/23 to 02/15/23 revealed documentation of meal intake percentages on only 01/30/23 lunch, 01/31/23 dinner, 02/04/23 dinner and 02/05/23 dinner. On 02/14/23 at 2:15 P.M. interview with the Director of Nursing verified lack of documentation for evidence of meal assistance provided and monitoring of meal intakes for Resident #9. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 19 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on review of the Payroll Based Journal Staffing Data Report and staff interview, the facility failed to ensure staffing information was submitted as required. This had the potential to affect all residents within the facility. The facility census was 36. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 1 of 2022 for the months of of 10/01/22 through 12/31/22 revealed no evidence of information submitted by the facility for the months of November and December 2022. On 02/16/23 at 12:35 P.M. interview with the facility Administrator revealed the facility corporate office staff submitted the PBJ data and the Administrator unsure why no data had been submitted. On 02/16/23 at 12:47 P.M. additional interview with the facility Administrator verified there had been no PBJ information submitted for the facility for the months of November and December 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 20 of 21 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 366141 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Louisville Gardens Care Center 4466 Lynnhaven Avenue NE Louisville, OH 44641 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, interview, and policy review, the facility failed to provide a pneumococcal immunization. This affected one(Resident #32) of five residents reviewed for immunizations. The facility census was 36. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 11/09/22 with diagnoses including dementia, anxiety, depression, and hypertension. Review of Resident #32's medical record revealed there was documentation of the resident representative consenting on 11/10/22, for the resident to receive the pneumococcal vaccine. Further review of the medical record revealed Resident #32 had not received a pneumococcal immunization. During interview on 02/16/23 at 1:22 P.M., the Director of Nursing (DON) confirmed Resident #32 had given consent to receive the pneumococcal vaccine, however, she had not received the pneumococcal vaccine. Review of the facility's policy, Pneumococcal Vaccine, dated August 2016, revealed prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 21 of 21