Inspection·March 11, 2024

F 0600 arranged payment plans with Premier Staffing and Avalon Foods. Level of Harm - Immediate jeopardy to resident health or safety Interview on 02/27/24 at 9:25 A.M. with Licensed Practical Nurse (LPN) #201 revealed on the last payroll period dated 02/16/24 LPN #201's paycheck was returned due to insufficient funds. LPN #201 stated, I deposited my check on Friday 02/16/24 and on Wednesday 02/21/24 my bank contacted me because my paycheck had bounced. I notified the Administrator, and the company wired my paycheck into my account on Friday 02/23/24, but they did not pay for the wire fee my bank charged me. Residents Affected - Many Interview on 02/27/24 at 9:30 A.M. with Housekeeper #164 revealed on the last payroll period dated 02/16/24 Housekeeper #164's paycheck was returned due to insufficient funds. Housekeeper #164 stated, This was my first paycheck here at the facility. I had deposited my check into my bank account on that Friday of payday. Then my bank notified me the next week, like four days later, that my check was not cashed because of insufficient funds. I told my supervisor, and she notified the Administrator and then the company wired my money to the account on Friday 02/23/24, but I had to pay for the wiring fees. My husband wants me to quit working here because of not getting paid on time. Interview on 02/27/24 at 9:35 A.M. with the Housekeeping/Laundry Manager #108 revealed her paycheck was not cashed by the bank due to insufficient funds. Housekeeping/Laundry manager #108 stated, This was the second time my check has bounced. After the first time back in October, I had changed banks because my other one would hold my check up to two weeks until they cashed it. I deposited this check on Friday 02/16/24 and by the following Wednesday, 02/21/24, my bank notified me that this check had been returned due to insufficient funds. I notified the Administrator, and she had the company wire my money into my account on that Friday 02/23/24. I did have to pay for the fees from my bank, so I had to pay for my paycheck. Interview on 02/27/24 at 8:48 A.M. with LPN #202 revealed LPN #202's paycheck had been returned due to insufficient funds on the last pay day on 02/16/24. LPN #202 stated, I had deposited my check on Friday 02/16/24. I had heard that several people had their banks notify them on the following Wednesday that their check had been returned. I hadn't heard anything from my bank, so I thought things were good with my check and so I paid my Jeep payment and some other bills. On that Friday, 02/23/24, my bank contacted me had said that my paycheck had been returned due to insufficient funds. That made my Jeep payment return along with the other bills I had paid. I notified the Administrator, and the company wired my money into my account later that Friday, about 4:45 P.M. I had to pay for the wiring fees and the overdrawn fees, about $20.00, because the company did not cover those fees. Interview on 02/27/24 at 9:43 A.M. with State Tested Nursing Assistant (STNA) #134 revealed STNA #134's paycheck had been returned due to insufficient funds. STNA #134 stated, On this last pay day on 02/16/24 it was a Friday. My bank notified me that my check had bounced on the following Wednesday. I notified the Administrator, and she got the company to wire my money into my account on that Friday 02/23/24. I had to pay the wiring fees and the overdraft fees for the bounced check. Interview on 02/27/24 at 9:56 A.M. with STNA #132 revealed STNA #132's paycheck had been returned due to insufficient funds on the pay day dated 02/16/24. STNA #132 stated, I had deposited my check on that Friday of payday. But I didn't know that it had bounced because I had to get a new bank card. Then my bank notified me that my paycheck had been returned due to insufficient funds. I finally got my new card last week and the company had wired my money on that Friday 02/23/24 like everybody else who had issues with their money. Interview on 02/27/24 at 3:06 P.M. with LPN #112 revealed LPN #112's paycheck had been returned due (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 2 of 20 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 03/11/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many to insufficient funds. LPN #112 stated, This was the second time that this has happened to me about my checks. I only work as needed for the facility, but I'm not going to pick up anymore because of the issues with the paychecks. I had deposited my check on Monday 02/19/24 and then on Wednesday my bank contacted me had said that my check had bounced. I notified the Administrator and then the company wired my money into my account on that Friday 02/23/24. I had to pay the wiring fees which was about $15.00. Interview on 02/28/24 at 3:02 P.M. with Chief Financial Officer (CFO) #600 revealed there was a system funding error which caused the lack of funds to meet payroll on the pay day dated 02/16/24. CFO #600 stated, There was an error with the positive pay files. We have taken different steps as far as how the files are uploaded into the system now and the process is now started a couple days prior to payday instead of the night before payday. CFO #600 shared starting the process earlier would help ensure the files were uploaded accurately. Interview on 02/28/24 at 3:21 P.M. with the Administrator revealed there were 16 staff members who had their paychecks returned due to insufficient funds on the payday dated 02/16/24. The Administrator verified employees were paid every two weeks. The Administrator stated, I notified the corporate office as soon as the staff notified me of the problems with their paychecks being returned, it was the following Wednesday 02/21/24 that the staff were notified by their banks. The company then wired the money into their (the employee) accounts on that Friday 02/23/24. The CFO never told me what the problem was that caused the paychecks to be returned. Review of the facility provided list of employees with returned/bounced paychecks on 02/16/24 identified Receptionist #200, Business Office Manager #100, Social Services #220, Activity Director #106, Housekeeping Supervisor #108, Housekeeper/Laundry #162 and #164, Dietary Aide #154, State Tested Nursing Assistant (STNA) #132, #134, #136, #142, #144 and Licensed Practical Nurse (LPN) #112, #201 and #202 were affected. Observation on 03/01/24 from 9:30 A.M. to 11:45 A.M. revealed Business Office Manager (BOM) #100 passing out the staff paychecks to staff members. The paychecks were issued as paper checks and required the staff to deposit into their bank accounts for processing. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated on 02/16/24 there was also an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those are paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) # 601, Director of Finances (DOF) #603 and he (CFO #600) handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Astoria Place of Barnesville. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. They stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 3 of 20 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 03/11/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many rejected. He confirmed he had no evidence from the bank it was a banking error. In addition to the staff pay roll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 today. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 12:00 P.M. an interview with BOM #100 revealed all the staff payroll checks were being returned for insufficient funds from the 03/01/24 pay date. She stated she had received texts and telephone calls from staff yesterday (03/03/24) and today. She stated she was sending the information to the facility's corporate office so they could wire transfer the money to the employees' accounts. She stated Social Service #220 and STNA #146 quit yesterday (03/03/24) due to their pay not clearing and 22 employees (STNA #132, #130, #144, #142, #134 and #146; LPN #120, #112, #124, #210, #202, #126; Dietary #154, #158, #152; Maintenance #104, BOM #100, Receptionist #200, Social Service #220, Housekeeping #164 and 108; and Hospitality Aide #168) have had their checks return from the 03/01/24 pay for insufficient funds as of this time. The BOM shared the prior Administrator resigned effective 03/01/24 due to the facility's financial issues (missed payroll and payments to vendors/outside services). On 03/04/24 at 12:20 P.M. an interview with STNA #134 revealed her bank had called her today to inform her that funds had been wired transferred into her account but not until today for her paycheck. On 03/04/24 at 12:22 P.M. an interview with LPN #116 revealed his check from 03/01/24 had been returned for insufficient funds. He stated the money and fees were wired into his bank account but not until today. On 03/04/24 at 12:24 P.M. an interview with STNA #132 revealed this was the fourth time her paycheck had not cleared the bank and the second pay in a row (02/16/24 and 03/01/24) that had not cleared. She stated she still had not been paid from the 03/01/24 pay as of this date. On 03/04/24 at 12:26 P.M. an interview with Laundry #162 revealed this was the second time her paycheck had not cleared the bank. The first time was 02/16/24 and this pay was the second time. She stated she still had not been paid from the 03/01/24 as of this date. On 03/07/24 at 11:21 A.M. a telephone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met and stated this was due to an identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation has been provided. On 03/07/24 at 2:48 P.M. an interview with BOM #100 revealed the paycheck from 03/01/24 for Dietary #156 had been returned for insufficient funds. She stated the wire transfers (from the corporation) were starting to clear the bank (six days after the expected pay day for the employees). On 03/08/24 at 10:40 A.M. an interview with BOM #100 revealed the paycheck from 03/01/24 for Dietary #155 had been returned for insufficient funds. The BOM stated she was still waiting on several (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 4 of 20 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 03/11/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many wire transfers to clear from the bank. (The BOM did not share which staff were awaiting wire transfers to clear as of this time). On 03/11/24 at 8:50 A.M. an interview with the BOM #100 revealed the paychecks for LPN #118, STNA #136, Marketing #300, and Maintenance #301 had been returned for insufficient funds. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: a. Review of the Dominion Energy statement dated 02/15/24 revealed the facility had a past due amount of $2690.71 and a current amount of $2276.73 for a total amount due by 03/04/24 of $4967.44. The statement indicated it was a shut off notice and $2690.71 needed to be paid by 03/04/24 to prevent the gas from being shut off. Review of the Dominion Energy receipt dated 03/01/24 revealed the facility paid $2670.71 to prevent the gas from being shut off. b. On 03/04/24 at 10:54 A.M. an interview with Physician #130 revealed he had not been paid for almost a year. He stated he received a paper check in November 2023, but it bounced. He stated he had called the corporate office in Florida and just gets the run-a-around. He stated that although he did not have any current plans to discontinue services at this this time, he hoped the company resolved the issue. The facility did not have evidence Physician #130 had been paid for services. c. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023 however CFO #600 stated they were sending out checks this week. Review of the email from Broad River Therapy dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $82,149.01. The following invoices were provided: invoice dated 11/02/23 and due on 12/02/23 was 94 days past due for the amount of $17,359.07; invoice dated 12/01/23 and due on 12/31/23 was 65 days past due for the amount of $21,299.52; an invoice dated 01/02/24 and due on 02/01/24 was 33 days past due for the amount of $23,103.50; and an invoice dated 02/02/24 and due on 03/03/24 was two days past due for the amount of $20,386.92. d. Review of Republic Services (trash) invoice dated 02/18/24 revealed the facility had a 30-day past due amount of $1,020.05 due now and a current amount of $1,046.61 due 03/09/24 for a total due of $2,066.66. As of 03/10/24, this had not been paid. e. Review of the NutriTech Consulting company's invoice dated 01/31/24 revealed the facility had the amount of $843.75 due for nutrition services/consult rendered. On 03/04/24 at 12:39 P.M. an interview with Dietitian #135 revealed the facility has to pre-pay for services because she has heard from other suppliers there were concerns with receiving payment. She stated today would have been the day they terminated services as they had not received their pre-payment from the facility, but the corporation did reach out this morning and paid the amount they owed. The facility now has until 03/11/24 to pay the March bill or services would be disrupted. An additional interview on 03/04/24 at 1:40 P.M. with Dietitian # 135 revealed the was 60 days past (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 5 of 20 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 03/11/2024 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many due. She had them prepay ahead for services. She stated she had to call them repeatedly for payment but had never cut services due to non-payment until 03/01/24. She stated they paid this morning, so they were not without a dietitian. Review of the email from Dietitian #135 on 03/07/24 at 10:42 A.M. revealed invoice number 2025 was due on 12/31/23 but wasn't paid until 03/05/24 via electric check and the check was returned for insufficient funds. The facility was currently working on a wire transfer. She stated there would not be a hold on services provided the wire transfer cleared the account. She also shared the facility dietitian was at the facility 03/06/34 to provide services. Further review revealed invoice number 2092 was due on 01/31/24 and was 36 days past due and needed to be paid by 03/11/24 to continue services. Invoice number 2142 due 03/01/24 was still within the 30-day grace period and only six days past due. A follow-up interview on 03/11/24 with Dietitian #135 revealed if payment was not made on this date, services would be terminated. f. On 03/11/24 at 12:54 P.M. interview with the Director of Operations #302 from Premiere Staffing revealed the facility made one payment since services were initiated in October 2023 and that payment was last week. Further interview revealed the facility canceled services with her company last week despite having an agency staff scheduled for a shift and did not have any of her staff scheduled for this week. Director of Operations #302 stated if payment wasn't made this week, services would be stopped with the facility as she does not allow facilities to carry a balance over 90-120 days. Lastly, she stated she issues an invoice weekly, on Thursday, to notify the facility of the amount owed but no payments have been routinely made as previously planned. A follow-up interview at 2:28 P.M. revealed the facility paid the October and November 2023 balance of $4,930.50 last week. The facility still owed $15,225.00 which was for services from December 2023 through 03/07/24. Review of the invoices from Premier Staffing revealed in January 2024, the facility total was $4,800.00 for January and in February 2024 the facility total for February was $6,787.50. Review of the (un-dated) Nursing Facility admission Agreement, provided to all residents upon admission, revealed the facility was responsible for basic services including room and board, routine nursing care and supplies for residents and such other personal services as may be necessary for the resident's health, well-being and grooming. The facility would also provide meals, linens, housekeeping, social services and activities and other regular services required by law. Review of the Employee Handbook, dated 2020, revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the Facility assessment dated [DATE] revealed the facility's residents were at a clinically complex and special high categories who oftentimes have one or more chronic or comorbid conditions including their acuity. Residents of the facility were at risk for falls, pressure ulcers, infections, incontinence, increased disability, weight loss, depression, and other potential areas of decline. Review of the facility's policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy revised 08/15/22 revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 6 of 20 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 03/11/2024 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 0600 This deficiency represents non-compliance investigated under Complaint Number OH00151331. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 7 of 20 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 03/11/2024 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 record review and interview, the facility failed to ensure residents received showers as planned and based on their preference. This affected two residents (#12 and #13) of five residents reviewed for showers. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 01/18/22 with diagnoses including diabetes mellitus, asthma, respiratory failure and prostate cancer. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. The assessment revealed the resident required substantial or maximum assistance for oral hygiene, toileting, showering or bathing and personal hygiene and was dependent on staff for eating. The assessment also noted it was very important to the resident to choose between a tub bath, shower, bed bath or a sponge bath. Review of the shower schedule revealed the resident preferred to receive a shower on Tuesday and Saturdays. Review of the State Tested Nurses Aide (STNA) task documentation dated 01/26/24 through 02/26/24 revealed Resident #12 received a shower on 02/03/24, 02/13/23 and 02/17/24. Staff documented he refused a shower on 02/10/24. Review of shower sheets dated 11/21/23 through 02/26/24 revealed the resident did not receive a shower on 12/02/23, 12/30/23, 01/06/24, 02/06/24 or 02/13/24 as scheduled. Resident #12 was unavailable for interview on this date (02/26/24) as the resident was in the hospital. However, information obtained from the resident's guardian revealed the resident was supposed to get two showers per week and that was not happening. The guardian voiced concerns that every time she met him at an appointment he was unkempt and not clean. Interview on 02/26/24 at 12:40 P.M. with Licensed Practical Nurse (LPN) #202 revealed the facility used a shower schedule to determine which resident was supposed to receive a shower on any given day and most residents were to receive a shower two times per week. The STNA staff documented when a shower was given and then gave the form to the nurse to verify. The form was placed in the shower book. She confirmed if a resident refused, it should be documented. Interview with the Administrator on 02/27/24 at 10:40 A.M. verified no additional information was available to determine showers had been provided to Resident #12 as scheduled. Review of the facility policy titled Bath, Shower/Tub dated February 2018 revealed the purpose of a shower or bath was to promote cleanliness and provide comfort to the resident. Documentation for a shower or bath would include the date, and time of a shower/tub bath would be documented, as well as refusals and any interventions taken. 2. Review of the medical record for Resident #13 revealed an admission date of 08/31/22 with diagnoses including chronic obstructive pulmonary disease (COPD), stroke, adult failure to thrive, anxiety and anemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 8 of 20 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 03/11/2024 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 Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed the resident required substantial or maximum assistance for toileting, showering or bathing and personal care and supervision for oral hygiene. The assessment also noted it was somewhat important for the resident to choose between a tub bath, shower, bed bath or sponge bath. Review of the shower schedule revealed the resident preferred to receive a shower on Tuesdays and Fridays. Review of the shower sheets dated 11/22/23 through 02/22/24 revealed Resident #13 did not receive a shower on 11/24/23, 11/28/23, 12/01/23, 12/26/23, 01/02/24, 01/16/24, 01/19/24, 01/26/24, 01/30/24, 02/02/24 or 02/09/24 as scheduled. Interview on 02/26/24 at 12:40 P.M. with Licensed Practical Nurse (LPN) #202 revealed the facility used a shower schedule to determine which resident was supposed to receive a shower on any given day and most residents were to receive a shower two times per week. The STNA staff documented when a shower was given and then gave the form to the nurse to verify. The form was placed in the shower book. She confirmed if a resident refused, it should be documented. Interview with the Administrator on 02/27/24 at 10:40 A.M. verified no additional information was available to determine showers had been provided to Resident #13 as scheduled. Review of the facility policy titled Bath, Shower/Tub dated February 2018 revealed the purpose of a shower or bath was to promote cleanliness and provide comfort to the resident. Documentation for a shower or bath would include the date, and time of a shower/tub bath would be documented, as well as refusals and any interventions taken. This deficiency represents noncompliance investigated under Complaint Number OH00151258. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 9 of 20 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 03/11/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interview the facility failed to ensure the use of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 32 residents residing in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility triggered for no RN hours. Continued review of the reporting data, as submitted by the facility revealed the facility had no RN hours on 07/06/23, 07/07/23, 07/11/23, 07/12/23, 07/16/23, 07/20/23, 07/21/23, 07/25/23, 07/26/23, 08/30/23 or 08/31/23. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to Centers for Medicare and Medicaid (CMS). The Administrator verified the information as noted on the PBJ report for Fiscal Year (FY) Quarter 4 2023 as noted above. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 10 of 20 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 03/11/2024 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure posted nursing staff information was updated in a timely manner. This had the potential to affect all 32 residents residing in the facility. Residents Affected - Many Findings include: Observation of the posted nursing staff information on 02/26/24 at 7:34 A.M. revealed the posted nursing staff information was dated 02/05/24. Interview on 02/26/24 at 8:02 A.M. with Receptionist #200 confirmed the posted staffing information had not been updated since 02/05/24. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 11 of 20 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 03/11/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, the facility submitted plan of correction to the state agency, facility assessment review, and interviews, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 32 residents in the facility. Findings include: Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various supplies/vendors removing the likelihood of situations of neglect. However, at the time of post-survey revisit on 02/08/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance and Performance Improvement Program was effective to ensure on-going compliance with the delivery of care. During the onsite investigation, completed on 03/11/24 the following concerns were identified: a. Interview on 02/28/24 at 3:02 P.M. with Chief Financial Officer (CFO) #600 revealed there was a system funding error which caused the lack of funds to meet payroll on the pay day dated 02/16/24. CFO #600 stated, There was an error with the positive pay files. We have taken different steps as far as how the files are uploaded into the system now and the process is now started a couple days prior to payday instead of the night before payday. CFO #600 shared starting the process earlier would help ensure the files were uploaded accurately. Interview on 02/28/24 at 3:21 P.M. with the Administrator revealed there were 16 staff members who had their paychecks returned due to insufficient funds on the payday dated 02/16/24. The Administrator verified employees were paid every two weeks. The Administrator stated, I notified the corporate office as soon as the staff notified me of the problems with their paychecks being returned, it was the following Wednesday 02/21/24 that the staff were notified by their banks. The company then wired the money into their (the employee) accounts on that Friday 02/23/24. The CFO never told me what the problem was that caused the paychecks to be returned. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated on 02/16/24 there was also an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those are paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 12 of 20 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 03/11/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) # 601, Director of Finances (DOF) #603 and he (CFO #600) handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Astoria Place of Barnesville. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. They stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank it was a banking error. In addition to the staff pay roll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 today. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 12:00 P.M. an interview with BOM #100 revealed all the staff payroll checks were being returned for insufficient funds from the 03/01/24 pay date. She stated she had received texts and telephone calls from staff yesterday (03/03/24) and today. She stated she was sending the information to the facility's corporate office so they could wire transfer the money to the employees' accounts. She stated Social Service #220 and STNA #146 quit yesterday (03/03/24) due to their pay not clearing and 22 employees (STNA #132, #130, #144, #142, #134 and #146; LPN #120, #112, #124, #210, #202, #126; Dietary #154, #158, #152; Maintenance #104, BOM #100, Receptionist #200, Social Service #220, Housekeeping #164 and 108; and Hospitality Aide #168) have had their checks return from the 03/01/24 pay for insufficient funds as of this time. The BOM shared the prior Administrator resigned effective 03/01/24 due to the facility's financial issues (missed payroll and payments to vendors/outside services). On 03/07/24 at 11:21 A.M. a telephone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met and stated this was due to an identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation has been provided. b. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: Review of the Dominion Energy statement dated 02/15/24 revealed the facility had a past due amount of $2690.71 and a current amount of $2276.73 for a total amount due by 03/04/24 of $4967.44. The statement indicated it was a shut off notice and $2690.71 needed to be paid by 03/04/24 to prevent the gas from being shut off. Review of the Dominion Energy receipt dated 03/01/24 revealed the facility paid $2670.71 to prevent the gas from being shut off. On 03/04/24 at 10:54 A.M. an interview with Physician #130 revealed he had not been paid for almost a year. He stated he received a paper check in November 2023, but it bounced. He stated he had called the corporate office in Florida and just gets the run-a-around. He stated that although he did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 13 of 20 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 03/11/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not have any current plans to discontinue services at this this time, he hoped the company resolved the issue. The facility did not have evidence Physician #130 had been paid for services. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023 however CFO #600 stated they were sending out checks this week. Review of the email from Broad River Therapy dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $82,149.01. The following invoices were provided: invoice dated 11/02/23 and due on 12/02/23 was 94 days past due for the amount of $17,359.07; invoice dated 12/01/23 and due on 12/31/23 was 65 days past due for the amount of $21,299.52; an invoice dated 01/02/24 and due on 02/01/24 was 33 days past due for the amount of $23,103.50; and an invoice dated 02/02/24 and due on 03/03/24 was two days past due for the amount of $20,386.92. Review of Republic Services (trash) invoice dated 02/18/24 revealed the facility had a 30-day past due amount of $1,020.05 due now and a current amount of $1,046.61 due 03/09/24 for a total due of $2,066.66. As of 03/10/24, this had not been paid. Review of the NutriTech Consulting company's invoice dated 01/31/24 revealed the facility had the amount of $843.75 due for nutrition services/consult rendered. On 03/04/24 at 12:39 P.M. an interview with Dietitian #135 revealed the facility has to pre-pay for services because she has heard from other suppliers there were concerns with receiving payment. She stated today would have been the day they terminated services as they had not received their pre-payment from the facility, but the corporation did reach out this morning and paid the amount they owed. The facility now has until 03/11/24 to pay the March bill or services would be disrupted. An additional interview on 03/04/24 at 1:40 P.M. with Dietitian # 135 revealed the was 60 days past due. She had them prepay ahead for services. She stated she had to call them repeatedly for payment but had never cut services due to non-payment until 03/01/24. She stated they paid this morning, so they were not without a dietitian. Review of the email from Dietitian #135 on 03/07/24 at 10:42 A.M. revealed invoice number 2025 was due on 12/31/23 but wasn't paid until 03/05/24 via electric check and the check was returned for insufficient funds. The facility was currently working on a wire transfer. She stated there would not be a hold on services provided the wire transfer cleared the account. She also shared the facility dietitian was at the facility 03/06/34 to provide services. Further review revealed invoice number 2092 was due on 01/31/24 and was 36 days past due and needed to be paid by 03/11/24 to continue services. Invoice number 2142 due 03/01/24 was still within the 30-day grace period and only six days past due. A follow-up interview on 03/11/24 with Dietitian #135 revealed if payment was not made on this date, services would be terminated. On 03/11/24 at 12:54 P.M. interview with the Director of Operations #302 from Premiere Staffing revealed the facility made one payment since services were initiated in October 2023 and that payment was last week. Further interview revealed the facility canceled services with her company last week despite having an agency staff scheduled for a shift and did not have any of her staff scheduled for this week. Director of Operations #302 stated if payment wasn't made this week, services would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 14 of 20 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 03/11/2024 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 0837 Level of Harm - Minimal harm or potential for actual harm stopped with the facility as she does not allow facilities to carry a balance over 90-120 days. Lastly, she stated she issues an invoice weekly, on Thursday, to notify the facility of the amount owed but no payments have been routinely made as previously planned. A follow-up interview at 2:28 P.M. revealed the facility paid the October and November 2023 balance of $4,930.50 last week. The facility still owed $15,225.00 which was for services from December 2023 through 03/07/24. Residents Affected - Many Review of the invoices from Premier Staffing revealed in January 2024, the facility total was $4,800.00 for January and in February 2024 the facility total for February was $6,787.50. Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator and to the compliance and ethics officer by scheduling executive board sessions with the compliance and ethics officer that allows for a free flow of information without potential for conflict. The governing body consisted of Chief Financial Officer #203, Chief Executive, Officer #204, and Chief Nursing Officer/Compliance Officer #205. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. Review of the administrator job description revealed they would operate the facility in accordance with the established policies and procedures of the facility. The job description indicated the administrator would supervise the recruitment, employment, and discharge of staff. And work closely with DON to ensure there were adequate numbers of staff to meet the needs of each resident and to comply with the state of Ohio licensure law. The administrator would act as a liaison with the facility owners and the medical, nursing, and other supervisory staff through regular meetings. This deficiency represents non-compliance investigated under Complaint Number OH00151331. This deficiency is also an example of continued non-compliance to the survey dated 02/08/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 15 of 20 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 03/11/2024 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 - Minimal harm or potential for actual 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 record review and interview the facility failed to ensure staffing information submitted to the Centers for Medicare and Medicaid (CMS) was complete and accurate. This had the potential to affect all 32 residents in the facility. Findings Include: Review of the Payroll Based Journal (PBJ) report for Fiscal Year (FY) Quarter 3 2023 (04/01/23 through 06/30/2023) revealed the facility triggered for a one star staff rating and excessively low weekend staffing. Review of the PBJ report for Fiscal Year (FY) Quarter 4 2023 (07/01/23 through 09/30/23) revealed the facility continued to trigger for a one star rating. Review of the PBJ report for Fiscal Year (FY) Quarter 1 2024 (10/01/23 through 12/30/23) revealed the the facility continued to trigger for a one star rating. This report was the most recent report available for review at the time of the investigation. Interview on 02/26/24 at 11:23 A.M. with the Administrator revealed she was responsible for submitting PBJ data to CMS. The Administrator verified the facility had triggered with a one star staff rating and excessively low weekend staffing on the PBJ reports as noted above. The Administrator indicated she believed the information submitted was likely submitted in error, resulting in the triggers. This deficiency is an example of noncompliance investigated under Complaint Number OH00151258. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 16 of 20 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 03/11/2024 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 32. Residents Affected - Many Findings include: Review of the provided QAPI documentation for December 2023 and January 2024, revealed an identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with the Administrator and Business Office Manager were to be completed weekly. Review of the facility survey history revealed on 11/15/23 a complaint survey was completed which resulted in concerns related to financial solvency. A plan of correction was submitted to the state agency to correct the deficient practice of not paying invoices on time in which the facility/company would pay any outstanding balance to vendors through payment plans if the past due invoice could not be paid in full. Following the 11/15/23 survey, the facility provided evidence of payments being made to various supplies/vendors removing the likelihood of situations of neglect. However, at the time of post-survey revisit on 02/08/24, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance and Performance Improvement Program was effective to ensure on-going compliance with the delivery of care. During the onsite investigation, completed on 03/11/24 the following concerns were identified: a. Interview on 02/28/24 at 3:02 P.M. with Chief Financial Officer (CFO) #600 revealed there was a system funding error which caused the lack of funds to meet payroll on the pay day dated 02/16/24. CFO #600 stated, There was an error with the positive pay files. We have taken different steps as far as how the files are uploaded into the system now and the process is now started a couple days prior to payday instead of the night before payday. CFO #600 shared starting the process earlier would help ensure the files were uploaded accurately. Interview on 02/28/24 at 3:21 P.M. with the Administrator revealed there were 16 staff members who had their paychecks returned due to insufficient funds on the payday dated 02/16/24. The Administrator verified employees were paid every two weeks. The Administrator stated, I notified the corporate office as soon as the staff notified me of the problems with their paychecks being returned, it was the following Wednesday 02/21/24 that the staff were notified by their banks. The company then wired the money into their (the employee) accounts on that Friday 02/23/24. The CFO never told me what the problem was that caused the paychecks to be returned. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys on 12/04/23 and 01/31/24. He stated on 02/16/24 there was also an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those are paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 17 of 20 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 03/11/2024 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) # 601, Director of Finances (DOF) #603 and he (CFO #600) handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Astoria Place of Barnesville. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. They stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank it was a banking error. In addition to the staff pay roll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 today. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 12:00 P.M. an interview with BOM #100 revealed all the staff payroll checks were being returned for insufficient funds from the 03/01/24 pay date. She stated she had received texts and telephone calls from staff yesterday (03/03/24) and today. She stated she was sending the information to the facility's corporate office so they could wire transfer the money to the employees' accounts. She stated Social Service #220 and STNA #146 quit yesterday (03/03/24) due to their pay not clearing and 22 employees (STNA #132, #130, #144, #142, #134 and #146; LPN #120, #112, #124, #210, #202, #126; Dietary #154, #158, #152; Maintenance #104, BOM #100, Receptionist #200, Social Service #220, Housekeeping #164 and 108; and Hospitality Aide #168) have had their checks return from the 03/01/24 pay for insufficient funds as of this time. The BOM shared the prior Administrator resigned effective 03/01/24 due to the facility's financial issues (missed payroll and payments to vendors/outside services). On 03/07/24 at 11:21 A.M. a telephone interview with CFO #600, Chief Executive Officer (CEO) #601 and Chief Nursing Officer (CNO) #602 was held. Chief Financial Officer #600 continued to report payroll was not met and stated this was due to an identified positive payroll issue with the bank. Documentation of the bank's error with the positive payroll file submission was requested. As of 03/11/24 at 11:00 A.M. no documentation has been provided. b. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: Review of the Dominion Energy statement dated 02/15/24 revealed the facility had a past due amount of $2690.71 and a current amount of $2276.73 for a total amount due by 03/04/24 of $4967.44. The statement indicated it was a shut off notice and $2690.71 needed to be paid by 03/04/24 to prevent the gas from being shut off. Review of the Dominion Energy receipt dated 03/01/24 revealed the facility paid $2670.71 to prevent the gas from being shut off. On 03/04/24 at 10:54 A.M. an interview with Physician #130 revealed he had not been paid for almost a year. He stated he received a paper check in November 2023, but it bounced. He stated he had called the corporate office in Florida and just gets the run-a-around. He stated that although he did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 18 of 20 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 03/11/2024 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many not have any current plans to discontinue services at this this time, he hoped the company resolved the issue. The facility did not have evidence Physician #130 had been paid for services. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023 however CFO #600 stated they were sending out checks this week. Review of the email from Broad River Therapy dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $82,149.01. The following invoices were provided: invoice dated 11/02/23 and due on 12/02/23 was 94 days past due for the amount of $17,359.07; invoice dated 12/01/23 and due on 12/31/23 was 65 days past due for the amount of $21,299.52; an invoice dated 01/02/24 and due on 02/01/24 was 33 days past due for the amount of $23,103.50; and an invoice dated 02/02/24 and due on 03/03/24 was two days past due for the amount of $20,386.92. Review of Republic Services (trash) invoice dated 02/18/24 revealed the facility had a 30-day past due amount of $1,020.05 due now and a current amount of $1,046.61 due 03/09/24 for a total due of $2,066.66. As of 03/10/24, this had not been paid. Review of the NutriTech Consulting company's invoice dated 01/31/24 revealed the facility had the amount of $843.75 due for nutrition services/consult rendered. On 03/04/24 at 12:39 P.M. an interview with Dietitian #135 revealed the facility has to pre-pay for services because she has heard from other suppliers there were concerns with receiving payment. She stated today would have been the day they terminated services as they had not received their pre-payment from the facility, but the corporation did reach out this morning and paid the amount they owed. The facility now has until 03/11/24 to pay the March bill or services would be disrupted. An additional interview on 03/04/24 at 1:40 P.M. with Dietitian # 135 revealed the was 60 days past due. She had them prepay ahead for services. She stated she had to call them repeatedly for payment but had never cut services due to non-payment until 03/01/24. She stated they paid this morning, so they were not without a dietitian. Review of the email from Dietitian #135 on 03/07/24 at 10:42 A.M. revealed invoice number 2025 was due on 12/31/23 but wasn't paid until 03/05/24 via electric check and the check was returned for insufficient funds. The facility was currently working on a wire transfer. She stated there would not be a hold on services provided the wire transfer cleared the account. She also shared the facility dietitian was at the facility 03/06/34 to provide services. Further review revealed invoice number 2092 was due on 01/31/24 and was 36 days past due and needed to be paid by 03/11/24 to continue services. Invoice number 2142 due 03/01/24 was still within the 30-day grace period and only six days past due. A follow-up interview on 03/11/24 with Dietitian #135 revealed if payment was not made on this date, services would be terminated. On 03/11/24 at 12:54 P.M. interview with the Director of Operations #302 from Premiere Staffing revealed the facility made one payment since services were initiated in October 2023 and that payment was last week. Further interview revealed the facility canceled services with her company last week despite having an agency staff scheduled for a shift and did not have any of her staff scheduled for this week. Director of Operations #302 stated if payment wasn't made this week, services would be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 19 of 20 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 03/11/2024 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 0865 Level of Harm - Minimal harm or potential for actual harm stopped with the facility as she does not allow facilities to carry a balance over 90-120 days. Lastly, she stated she issues an invoice weekly, on Thursday, to notify the facility of the amount owed but no payments have been routinely made as previously planned. A follow-up interview at 2:28 P.M. revealed the facility paid the October and November 2023 balance of $4,930.50 last week. The facility still owed $15,225.00 which was for services from December 2023 through 03/07/24. Residents Affected - Many Review of the invoices from Premier Staffing revealed in January 2024, the facility total was $4,800.00 for January and in February 2024 the facility total for February was $6,787.50. Review of the facility policy dated February 2020 titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. This deficiency represents non-compliance investigated under Complaint Number OH00151331. This deficiency is also an example of continued non-compliance from the survey dated 02/08/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 20 of 20