Inspection·December 11, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure medications were available to administer to Resident #21 and Resident #39 in a timely manner. This affected two residents (#21 and #39) out of five residents reviewed for medication administration. The facility census was 66.Findings include:1. A review of Resident #21's clinical record revealed an admission date of 10/23/25 with diagnoses including pleural effusion, hemiplegia and hemiparesis following a stroke, atelectasis, trouble swallowing, cognitive communication deficit, tracheostomy, epilepsy, malnutrition, type two diabetes mellitus, chronic pancreatitis, depression, anxiety, high cholesterol and blood pressure, and acute/chronic respiratory failure requiring ventilator support.A review of Resident #21's clinical record revealed an admission to the facility on [DATE] following a hospitalization for acute respiratory failure.A review of Resident #21's physician orders dated 10/23/25 revealed an order to administer lacosamide (medication used to control seizures) 150 milligrams (mg) via percutaneous endoscopic gastrostomy (PEG) tube two times a day.A review of Resident #21's Medication Administration Record (MAR) dated 10/01/25 to 10/31/25 indicated the lacosamide medication was not administered on 10/23/25 and 10/24/25.A review of Resident #21's nursing progress notes dated 10/24/25 indicated the lacosamide medication was not administered because the pharmacy needed a prescription for the medication.An interview with Licensed Practical Nurse (LPN) #79 on 12/10/25 at 8:58 A.M. revealed Resident #21's lacosamide medication was not available in the facility to administer to Resident #21. LPN #79 stated she notified Certified Nurse Practitioner (CNP) #80 who was in the facility at the time. CNP #80 called the pharmacy to inform them of the need for Resident #21's lacosamide medication. LPN #79 stated this occurred at the end of her shift and the oncoming nurse (unnamed) would need to administer the lacosamide medication when it arrived from the pharmacy.Three attempts to speak to the oncoming nurse (LPN #81) were unsuccessful from 12/09/25 to 12/11/25 and an interview with CNP #80 on 12/09/25 at 2:32 P.M. verified she had called the pharmacy on 10/24/25 to obtain the lacosamide medication for staff to administer to Resident #21. CNP #80 stated she was unaware the staff did not receive the lacosamide medication prior to Resident #21's readmission to the hospital on [DATE].An interview with the Director of Nursing (DON) on 12/10/25 at 10:43 A.M. verified the above findings and agreed the documentation revealed Resident #21 did not receive the lacosamide medication on 10/23/25 and 10/25/25.2. A review of Resident #39's clinical record revealed an admission date of 08/20/18 with diagnoses including cerebral palsy, epilepsy, profound intellectual disability, hypothyroidism, depression, high cholesterol, anxiety and senile degeneration of the brain.A review of Resident #39's clinical record revealed a physician order dated 02/10/25 to administer phenobarbital 32.4 mg (anticonvulsant) rectally three times a day.A review of Resident #39's MAR dated 12/01/25 to 12/31/25 indicated the phenobarbital medication was not administered from 10:00 P.M. on 12/02/25 to 2:00 P.M. on 12/06/25.A review of Resident #39's nursing progress notes dated 12/02/25 indicated an attempt to pull the phenobarbital medication from the facility's stocked medications was unsuccessful due to the pharmacy needed an updated prescription. The note indicated CNP #82 was notified. Multiple nursing progress notes dated 12/02/25 to 12/06/25 revealed several attempts were made to have the pharmacy deliver the phenobarbital rectal suppository medication, and the physician was notified as well.An interview with LPN #74 on 12/10/25 at 9:45 A.M. verified Resident #39's phenobarbital medication was not available in the facility to administer to Resident #39. LPN #74 stated she contacted the pharmacy and spoke to the pharmacy staff who informed her they were unable to provide the phenobarbital medication until a prescription was provided to the pharmacy. LPN #74 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 2 of 10 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 12/11/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete she emailed and sent two prescriptions for the phenobarbital medication to the pharmacy which the pharmacy denied receiving at least seven times. LPN #74 stated Resident #39 had seizures and was worried she would have a seizure due to not receiving her seizure medication. LPN #74 stated on 12/06/25 CNP #82 sent the prescription via electronic scripts, and the pharmacy finally delivered the phenobarbital medication. LPN #74 verified Resident #39 did not receive the phenobarbital medication from 12/02/25 to 12/06/25. LPN #74 stated Resident #39 received the phenobarbital medication on 12/06/25 at 5:40 P.M.An interview with the DON on 12/10/25 at 10:43 A.M. revealed she reviewed the nursing progress notes daily on all the residents in the facility and verified she was aware there were several doses of the phenobarbital medication missed from 12/02/25 to 12/06/25 due to the pharmacy did not deliver the medication. The DON stated she called the pharmacy herself to ensure after they received the electronic script on 12/06/25 that a drop shipment was made to deliver the phenobarbital medication promptly.The facility policy and procedure titled Medication Orders and Receipt Record, revised 04/2007, revealed the facility would document all medications that are ordered and received in the facility. The Charge Nurse would maintain medication order and receipt records. The DON Services would designate individuals to be responsible for completing medication order/receipt forms. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. Emergency medications ordered/received shall also be entered onto the medication order and receipt record. The receiving nurse shall record medication orders received on the receipt record. The receiving nurse shall verify each delivered medication and check off the order form. Controlled substances shall be verified in the presence of the person delivering the drug order. Noted discrepancies shall be reported to the dispensing pharmacy.This deficiency represents non-compliance investigated under Master Complaint Number 2688125. Event ID: Facility ID: 366141 If continuation sheet Page 3 of 10 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 12/11/2025 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility admission Agreement, interview and facility policy review, the facility failed to ensure Resident #7's admission paperwork was completed in a timely manner and Resident #44's medication administration documentation was accurate. This affected one resident (#7) out of three residents reviewed for admission paperwork and one resident (#44) out of three residents observed during medication administration. The facility census was 66.Findings include:Based on record review, review of the facility admission Agreement, interview and facility policy review, the facility failed to ensure Resident #7's admission paperwork was completed in a timely manner and Resident #44's medication administration documentation was accurate. This affected one resident (#7) out of three residents reviewed for admission paperwork and one resident (#44) out of three residents observed during medication administration. The facility census was 66.Findings include:1. A review of Resident #7's clinical record revealed an admission date of 03/31/25 and readmission date of 05/11/25 with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, mild dementia with agitation, deep vein thrombosis of lower extremity, asthma, depression, diabetes mellitus, type two, gastroesophageal reflux disease, heart failure, high blood pressure and cholesterol, and iron deficiency anemia.Review of the cognitive care plan note dated 09/22/25 and signed by the physician on 09/29/25 revealed a diagnosis of Dementia: Moderate in severity based on the recent local score, this patient does not have a diagnosed history of dementia, based on that Moca score, I would say she certainly should carry that diagnosis of dementia going forward, she does have a Power of Attorney (POA) in place which is her daughter I would encourage her to continue to utilize her listed decision-maker for assistance with needs or medical and financial decisions going forward.A review of Resident #7's admission Agreement revealed the documentation was completed on 09/30/25 and signed by Resident #7. (The resident had a Power of Attorney (POA) that should have been asked to sign the admission paperwork). An interview with Interim Administrator (IA) #76 on 12/10/25 at 11:36 A.M. verified the admission paperwork including the admission agreement was not completed in a timely manner for Resident #7.A review of the facility policy and procedure titled admission Agreement, dated 12/2006, indicated at the time of admission, the resident (or his/her representative) must sign an admission Agreement (contract) that outlines the services covered by the basic per diem rate, as well as any additional services requested by the resident that are not covered by the basic per diem rate.-The admission Agreement (contract) will reflect all charges for covered and non-covered items, as well as identify the parties that are responsible for the payment of such services.-With respect to our admission Agreement, our facility shall not: a. Require individuals applying to reside (or residing) in our facility to waive their rights to benefits under Medicare/Medicaid; b. Require oral or written assurances that such residents or applicants are not entitled or eligible for such benefits; c. Require oral or written assurances that such residents or applicants will not apply for such benefits; d. Require that the sponsor or legal guardian guarantee payment as a condition of admission, or to expedite the admission. (Note: An individual, or guardian, who has access to the resident's income or resources will be required to sign the admission Agreement guaranteeing payment from such funds for the care and services provided to the resident in accordance with the admission Agreement.); and e. In the case of a resident or applicant who is entitled to Medicare/Medicaid benefits for nursing care, charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under Medicare/Medicaid programs, any gift, money, donation, or other consideration as a precondition of admitting (or expediting the admission of) the applicant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 4 of 10 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 12/11/2025 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 to the facility or as a requirement for a resident's continued stay in the facility. (Note: This shall not be construed as preventing the facility from charging Medicare/Medicaid recipients for services the resident requested that are not covered by the facility's per diem rate.)- [NAME]-fide contributions may be accepted and solicited by the facility from a charitable, religious, or philanthropic organization or from a person unrelated to a resident (or potential resident), but only to the extent that such contribution is not a condition of admission, expediting admission, or continued stay in the facility.-A copy of the admission Agreement will be provided to the resident or his/her representative (sponsor), and a copy will be placed in the resident's permanent file.-Residents will be informed of any change(s) in the costs or availability of services at least sixty (60) days prior to such change(s) taking effect. Changes in services, charges, payments, etc., will require that new agreements be signed.-Inquiries concerning the facility's admission Agreement should be referred to the Administrator and/or business office.2. A review of Resident #44's clinical record revealed an admission date of 09/18/19 and readmission date of 08/13/21 with diagnoses including chronic obstructive pulmonary disease, anemia, fractured left arm, benign tumor of lower limb including hip, bipolar disorder, borderline personality disorder, hemorrhoids, obesity, heart failure, lymph node disorder with lymphedema, chronic left calf non-pressure ulcer, paroxysmal atrial fibrillation (irregular heart rate), chronic venous high blood pressure, type two diabetes mellitus with circulatory complications, anxiety, obstructive sleep apnea, post-traumatic stress disorder, insomnia, stage three chronic kidney disease, hoarding disorder, excessive and redundant skin disorder, overactive bladder, hypothyroidism, restless leg syndrome, vitamin D deficiency, neuropathy, rosacea, high cholesterol and blood pressure and gastroesophageal reflux disease.A review of Resident #44's physician orders and Medication Administration Record (MAR) dated 12/01/25 to 12/31/25 indicated to administer the following medications/treatments at 8:00 A.M. and/or 9:00 A.M.:-Aurality extended release 45-105 milligram (mg) (dextromethorphan, Hydrobromide-Bupropion Hydrochloride) (medication to treat major depressive disorder) one tablet orally-Cranberry oral tablet 450 mg (supplement) tablet orally- Flonase allergy relief nasal suspension 50 micrograms (mcg)/actuation (corticosteroid) one spray each nostril- Lidocaine external patch (local anesthetic) apply topically to shoulder for pain- Oxybutynin chloride extended release 15 mg orally (medication to treat overactive bladder)-Zinc 50 mg orally (supplement)-Zyrtec allergy 10 mg orally (antihistamine)- Cardizem Long Acting 240 mg orally (antiarrhythmic)- Gabapentin 300 mg orally (anticonvulsant)-Magnesium lactate extended release 84 mg orally (supplement)-Megestrol acetate 20 mg orally (hormone)-Metoprolol 50 mg orally (medication to treat high blood pressure, chest pain, and heart failure)- Mucinex extended release 600 mg orally (expectorant)-Artificial tears ophthalmic solution 1.4 percent instill one drop each eye-Vitamin C 1,000 mg orally (supplement)An observation on 12/10/25 at 7:32 A.M. of Licensed Practical Nurse (LPN) #77 administer medications to Resident #44 revealed a failure to document the medication administration accurately. LPN #77 administered the above listed medications but did not administer the Flonase nasal spray, Artificial Tears or Lidocaine patch.A review of Resident #44's MAR dated 12/01/25 to 12/31/25 revealed LPN #77 had documented the administration of the Flonase nasal spray, Artificial Tears and documented the Lidocaine patch was not available to administer to Resident #44.An interview with LPN #77 on 12/10/25 at 11:27 A.M. verified she had failed to administer the Flonase nasal spray and Artificial Tears at the time she administered the other medications because she usually completed her treatments at 10:00 A.M. LPN #77 verified she documented that she had administered the Flonase nasal spray and Artificial tears on Resident #44's MAR at 8:00 A.M. LPN #77 stated she would administer the Flonase and Artificial Tears at 10:00 A.M. LPN #77 stated the Lidocaine patch was not available to administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 5 of 10 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 12/11/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete at the time she administered the other medications to Resident #44, and she would call the pharmacy to have them deliver the Lidocaine patches to the facility.The facility policy titled Administering Medications, revised 04/2019, indicated medications are administered in a safe and timely manner, and as prescribed. Item number nine indicated medications are administered within one (1) hour of their prescribed time, unless otherwise specified. Item number 24 on the policy revealed 24. The individual administering the medication initials on the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Item number 25 indicated 25. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug.The facility policy titled Documentation of Medication Administration (undated) indicated1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's MAR.2. Administration of medication must be documented immediately after (never before) it is given.3. Documentation must include, as a minimum: a. Name and strength of the drug; b. Dosage. c. Method of administration (e.g., oral, injection (and site), etc.); d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused (as applicable); f. Signature and title of the person administering the medication; and g. Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.).This deficiency represents non-compliance investigated under Complaint Number 2640234. Event ID: Facility ID: 366141 If continuation sheet Page 6 of 10 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 12/11/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to maintain infection control practices to prevent the spread of the coronavirus-19 infection (COVID-19 / SA RS-Co Y-2) in the facility and failed to ensure staff performed hand hygiene to prevent cross contamination of germs during Resident #56's incontinence care. This affected four residents (#7, #30, #51, and #45) of 16 residents (#3, #6, #7, #14, #17, #26, #27, #30, #38, #44, #45, #51, #55, #56, #65, and #67) with a positive COVID-19 infection, one resident (#31) out of four residents reviewed for smoking tobacco products, one resident (#56) out of three residents reviewed for incontinence care. This had the potential to affect all the residents in the facility. The facility census was 66.Findings include:The facility identified 16 residents (Resident #3, Resident #6, Resident #7, Resident #14, Resident #17, Resident #26, Resident #27, Resident #30, Resident #38, Resident #44, Resident #45, Resident #51, Resident #55, Resident #56, Resident #65, Resident #67) who tested positive for COVID-19 in the facility from 11/26/25 to 12/09/25. A review of each of the residents' record listed above revealed a positive test for COVID-19 and a physician order for droplet isolation precautions.1. A review of Resident #7's clinical record revealed an admission date of 03/31/25 and readmission date of 05/11/25 with diagnoses including chronic obstructive pulmonary disease, pulmonary embolism, mild dementia with agitation, deep vein thrombosis of lower extremity, asthma, depression, diabetes mellitus, type two, gastroesophageal reflux disease, heart failure, high blood pressure and cholesterol, and iron deficiency anemia,A review of Resident #7's nursing progress note dated 12/08/25 indicated Resident #7's daughter, Power of Attorney (POA), was notified that Resident #7 had tested positive for COVID-19 infection.An observation on 12/09/25 at 9:24 A.M. of Resident #7's room revealed no signage to alert staff and visitors that personal protective equipment (PPE) should be worn due to isolation precautions for a resident who tested positive for the COVID-19 infection.An interview with Licensed Practical Nurse (LPN) #70 on 12/09/25 at 9:24 A.M. verified Resident #7 had tested positive for COVID-19 infection on 12/08/25, and staff should have placed a sign outside her room to alert the staff/visitors to wear PPE. LPN #70 verified there was no signage outside of Resident #7's room.An interview with the Director of Nursing (DON) on 12/09/25 at 9:58 A.M. stated the facility had an outbreak of COVID-19 infections. All residents who had tested positive for COVID-19 were supposed to have a sign posted on the door outside their room to alert staff and visitors to see the nurse before entering the resident's room and to wear PPE for isolation precautions. The facility followed CDC guidance to control the spread of the COVID-19 viral infection. The facility had six additional residents who had tested positive for COVID-19 on 12/08/25 and currently had 16 residents (#3, #6, #7, #14, #17, #26, #27, #30, #38, #44, #45, #51, #55, #56, #65, and #67) who had tested positive for COVID-19 with one resident (#67) currently in the hospital. 2. An interview with Resident #31 on 12/09/25 at 9:46 A.M. revealed she was concerned about contracting the COVID-19 virus. Resident #31 stated the staff allowed the residents who had tested positive for the COVID-19 viral infection to smoke at the same time as the residents who had tested negative for the COVID-19 infection.An interview with the DON on 12/09/25 at 9:58 A.M. verified the staff had allowed Resident #7 who had tested positive for COVID-19 to smoke with the residents who had tested negative for COVID-19 on 12/08/25.An interview with Resident #7 on 12/09/25 at 1:15 P.M. verified she had tested positive for COVID-19 infection on 12/08/25 and was allowed to smoke with the rest of the residents including the residents who had tested negative for COVID-19 infection.3. An observation and interview with LPN #74 on 12/10/25 from 7:00 A.M. to 7:43 A.M. revealed Resident #30's and Resident #51's room Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 7 of 10 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 12/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had a sign indicating droplet precautions be implemented when providing care. Resident #30 and Resident #51 resided together in one room, and the door was left open. LPN #74 stated both residents had tested positive for COVID-19 infection. LPN #74 verified the door was left open because the residents liked to have the door open. LPN #74 agreed the door had been left open for an extended period of time. An observation and interview with the Therapy Director on 12/10/25 at 9:21 A.M. verified Resident #45's door was open, and Resident #45 had a sign on the door to implement droplet isolation precautions when entering the room and verified Resident #45 had tested positive for COVID-19 infection.A review of the facility policy and procedure titled Coronavirus Disease (COVID-19) -Infection Prevention and Control Measures, dated 04/29/24, indicated the facility followed infection prevention and control (IPC) practices recommended by the CDC to prevent the transmission of COVID-19 within the facility. The infection prevention and control measures that are implemented to address the SA RS-Co Y-2 pandemic are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses;b. providing resources and counseling about the importance of receiving the COVID-19 vaccine;c. identifying and managing ill residents and staff;d. ensuring everyone is aware of recommended IPC practices in the facility, including the use of visual alerts with dates to reflect that recommendations are current; e. a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following criteria:Symptoms of COVID-19; or - close contact with someone with SARS-[NAME]-2 infection (for residents and visitors) or a higher-risk exposure (for healthcare personnel [HCP]).f. Implementing source control measures;g. implementing universal use of PPE for staff;h. optimizing engineering controls and indoor air qualityi. A positive viral test for SARS-[NAME]-2; following current environmental infection prevention and control recommendations;j. performing testing as recommended by current guidelines;k. responding to SARS-[NAME]-2 exposures; andl. implementing outbreak investigations when indicated. A review of the CDC's guidance titled infection Control Guidance: SARS-CoV-2 indicated this guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. The IPC (Infection Prevention Control) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing.Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multi-Drug Resistant Organisms (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process.Facilities could consider designating entire units within the facility, with dedicated Health Care Personnel (HCP), to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Limit transport and movement of the patient outside of the room to medically essential purposes.CDC infection control regarding laundry and bedding, dated 01/08/24, indicated the following guidance for laundry obtained from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 8 of 10 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 12/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patients/residents in isolation areas:When collecting, transporting, and sorting contaminated textiles and fabrics in healthcare facilities ensure bags of contaminated laundry are clearly identified with labels, color-coding or other methods so the healthcare workers handle the items safely, regardless of whether the laundry is transported within the facility or a designated off-site laundry service.4. A review of Resident #56's clinical record revealed an admission date of 08/26/25 with diagnoses including sepsis, stroke, skin cancer, vitamin B12 and Vitamin D deficiency, hypocalcemia (low calcium blood level), expressive language disorder, seizures, type two diabetes mellitus, right lower leg cellulitis, stage 3 chronic kidney disease, paroxysmal atrial fibrillation (irregular heart rhythm), atherosclerosis heart disease and right leg arteries, high blood pressure and cholesterol, gastroesophageal reflux disease, and depression.A review of Resident #56's care plan initiated on 08/26/25 indicated Resident #56 was at risk for bladder incontinence related to stage three kidney disease. A review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #56 was always incontinent of bladder.Interventions on the care plan included cleaning peri-area with each incontinence episode, monitor and document signs/symptoms of urinary tract infections, and possible causes of bladder incontinence including infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects.An observation of CNA #75 on 12/10/25 at 11:40 A.M. provide Resident #56 with incontinence care revealed a failure to perform hand hygiene to prevent cross contamination of germs. CNA #75 entered Resident #56's room and did not perform hand hygiene and donned a pair of gloves. CNA #75 obtained a soapy washcloth and cleaned Resident #56's perineal area and then rinsed the area with a warm wet washcloth and dried the area. CNA #75 then removed her glove from her left hand, did not perform hand hygiene and opened Resident #56's furniture drawer and moved personal items in the drawer around looking for moisture barrier cream. CNA #75 then donned another glove to her left hand and applied the moisture barrier cream to Resident #56's perineal area and then with the same gloved hands replaced the moisture barrier cream back in the drawer with Resident #56's other personal items without removing her gloves or performing hand hygiene. CNA #75 then removed her glove from her right hand, did not perform hand hygiene and used her right hand to readjust Resident #56's bed linens and use the bed remote to adjust the bed position. An interview with CNA #75 on 12/10/25 at 11:55 A.M. verified the above findings and agreed she should have performed hand hygiene after removing her each disposable glove and prior to starting the task.A review of the policy titled Handwashing/Hand Hygiene, dated 10/2023, indicated the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility.4. Personnel are educated regarding ways to prevent contact dermatitis and other skin irritation, and provided with supplies that support healthy hand skin.a. Facility-supplied lotions are compatible with antiseptics and gloves.b. ABHRs, soaps and lotions are free of allergenic surfactants, preservatives, fragrances and dyes.c. Triclosan-containing soaps are not recommended for use or supplied by the facility.5. Environmental measures are taken to reduce contamination associated with sinks and sink drainage, including:a. Hand washing sinks that are constructed and installed according to health department codes;b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366141 If continuation sheet Page 9 of 10 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 12/11/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Sinks that are dedicated to handwashing, when possible;c. The use of disinfectants that are EPA-registered for biofilm removal to clean sinks and faucets daily; andd. Surveillance for waterborne pathogens.6. Residents, family members and/or visitors are encouraged to practice hand hygiene. Fact sheets, pamphlets and/or other written materials promoting hand hygiene practices are provided at the time of admission and/or posted throughout the facility.Indications for hand hygiene included:1. Hand hygiene is indicated:a. immediately before touching a resident;b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device);c. after contact with blood, body fluids, or contaminated surfaces d. after touching a resident;e. after touching the resident's environment f. Before moving from work on a soiled body site to a clean body site on the same resident andg. immediately after glove removal2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 3. Wash hands with soap and water: a. when hands are visibly soiled; and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.4. Single-use disposable gloves should be used:a. before aseptic procedures; b. when anticipating contact with blood or body fluids; and c. when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 5. The use of gloves does not replace hand washing/hand hygiene.This deficiency represents non-compliance investigated under Master Complaint Number 2688125. Event ID: Facility ID: 366141 If continuation sheet Page 10 of 10