Health inspection·May 4, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were provided as required. This affected one (#44) of one resident reviewed for care conferences. The census was 58. Findings included: Medical record review for Resident #44 revealed an admission of 05/13/22. Medical diagnoses included Parkinson's disease, hypertension, and obstructive uropathy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 was cognitively intact. Resident #44's functional status was extensive assistance for bed mobility, transfers, and toilet use, and supervision was eating. Review of Resident #44's care conferences in the last year revealed a care conference was held on 05/24/22 and 12/08/22. The attendees at Resident #44's care conference were social services, nursing, and therapy. Interview with Resident #44 on 05/02/23 at 9:21 A.M. stated he had not been receiving care conferences. Interview with Social Services Coordinator (SSC) #125 on 05/03/23 at 11:33 A.M. confirmed Resident #44 had only two care conferences in the past year. SSC #125 stated if there were any problems for dietary or MDS concern the facility would follow-up with those departments with the concerns. Review of policy titled, Care Conference Policy and Procedure, dated 04/01/22, revealed it was the center's policy to offer care conferences to patients, residents, and authorized representatives on admission, quarterly, with a change in condition and when the patient, resident, or authorized representatives request a conference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 2 of 7 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 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 Based on observation, medical record review, and staff interview, the facility failed to ensure a resident's cervical collar was cleaned as ordered. This affected one (#6) of one resident reviewed for cleanliness of cervical collars. The census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 03/13/23 with diagnoses including fusion of the spine at the cervical region, encounter for other specified surgical aftercare, type two diabetes mellitus, history of falling, left anterior fascicular block, hypertension, hyperlipidemia, obesity, major depressive disorder, cognitive communication deficit, need for assistance with personal care, and generalized anxiety disorder. Review of a Minimum Data Set (MDS) MDS assessment for Resident #6 dated 04/08/23 revealed Resident #6 was assessed with moderately impaired cognition and required extensive assist for activities of daily living. Review of a care plan for Resident #6 dated 03/30/23 revealed the resident had an alteration in musculoskeletal status related to a cervical fracture with fusion. Interventions included observe the skin under the cervical collar, pads to the cervical collar to be cleaned daily, change the pads daily, and wash old pads in the sink or a basin of water with soap. Staff are to squeeze the pads to work the soap through the pad, rinse the pads well with clean water, squeeze the pads in the clean water to be sure to rinse out the soap, squeeze out any extra water, and lay the pads flat to dry. The pads should air dry in about an hour. Resident #6 was to wear the cervical collar at all times. Review of physician orders for May 2023 for Resident #6 revealed the pads to the cervical collar to be cleaned daily, change the pads daily, and wash old pads in the sink or basin of water with soap. Staff were to squeeze pads to work the soap through the pad, rinse the pads well with clean water, squeeze the pads in the clean water to be sure to rinse out the soap, squeeze out any extra water, and lay the pads flat to dry. The pads should air dry in about an hour and Resident #6 was to wear the cervical collar at all times. Staff may loosen the cervical collar for meals only, and reapply and readjust once Resident #6 was done eating. Observation on 05/01/23 at 1:20 P.M. of Resident #6 revealed a brown crusty substance speckled on the chin part of the cervical collar. Observation on 05/02/23 at 7:59 A.M. of Resident #6 revealed the same brown crusty substance speckled on the chin part of the cervical collar. Observation on 05/02/23 at 12:19 P.M. of Resident #6 revealed the inside of the cervical collar by Resident #6's chin remained dirty with same brown crusty substance. Interview on 05/02/23 at 12:43 P.M. with State Tested Nurse Aide (STNA) #152 verified the cervical collar padding under Resident #6's chin was dirty with dry crusty brown substance. STNA #152 stated she noticed it that morning and asked about it, and STNA #152 stated she believed the padding was to be cleaned daily. Observation on 05/03/23 at 8:15 A.M. of Resident #6 revealed the pad under Resident #6's chin of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 3 of 7 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 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 the cervical collar continued with same brown crusty substance. Level of Harm - Minimal harm or potential for actual harm Interview on 05/03/23 at 7:45 A.M. with STNA #152 verified the same brown crusty substance speckled down on chin pad of Resident #6's cervical collar remained in place. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 4 of 7 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, interview, and policy review, the facility failed to administer medications are ordered. This affected one (#4) of three residents reviewed for antibiotic usage. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #4 revealed admission date of 09/23/21 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, morbid obesity, epilepsy, heart failure, schizoaffective disorder, bipolar disorder, delusional disorder, anemia, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 03/05/23 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #4 required extensive assist for activities of daily living. Review of a nursing progress note dated 04/10/23 for Resident #4 revealed a new order received from a certified nurse practitioner (CNP) to extend the antibiotic ertapenem injection to a total of 10 days of administration. The pharmacy, resident, and guardian were notified. Review of the April 2023 medication administration record (MAR) for April 2023 revealed Resident #4 received ertapenem 1 gram on 04/06/23, 04/07/23, 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, and 04/13/23 for a total of eight days. Interview on 05/02/23 at 2:45 P.M. with Regional Clinical Nurse (RCN) #177 verified Resident #4 only received ertapenem for a total of eight days, and verified the order was extended for Resident #4 to received the medication for a total of 10 days. Review of an undated policy titled, Medication Orders, revealed new medication orders require facility name, date, resident's name, medication name, strength, specific directions for use, physician name, and nurse's full name ordering the medication. The following information, if appropriate, must be included when ordering, specific dosing parameters, stop dates or durations, contingency supply used, and do not send if pharmacy is not supplying medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 5 of 7 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #11 revealed an admission date of 08/05/21. Medical diagnoses included Parkinson's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired. Review of a physician order dated 03/14/23 for Resident #11 revealed the anti-anxiety medication lorazepam oral concentrate two milligrams per milliliter (mg/ml) to give 0.5 mg by mouth every four hours as needed for restlessness. 3. Medical record review for Resident #14 revealed an admission date of 07/10/22. Medical diagnoses included Alzheimer's disease with early onset. Review of the quarterly MDS assessment dated [DATE] revealed Resident #14 was severely cognitively impaired. Review of a physician order dated 03/17/23 for Resident #14 revealed lorazepam oral concentrate two mg/ml to give 0.25 mg at bedtime for anxiety. 4. Medical record review for Resident #15 revealed an admission date of 04/24/20. Medical diagnoses included Alzheimer's disease with late onset. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired. Review of a physician order dated 03/13/23 revealed lorazepam oral concentrate two mg/ml to give 0.25 mg every two hours as needed for anxiety or restlessness for 14 days. Observation on 05/03/23 at 8:49 A.M. revealed in the medication room on Care Center #1 a refrigerator that was unlocked. Further observation inside the refrigerator revealed four lorazepam two mg/ml oral concentrate vials. There were two vials for Resident #14, one vial for Resident #15, and one vial for Resident #11. Interview with LPN #144 on 05/03/23 at 9:00 A.M. confirmed the vials of lorazepam were in an unlocked refrigerator and stated the refrigerator used to locked. Review of the undated policy titled, Medication Storage, revealed all controlled substances are to be stored under a double lock and key. Only authorized facility staff is to have access to controlled substances. Based on observation, medical record review, and staff interview, the facility failed to ensure a medications were ingested at the time of administration and failed to ensure medications were properly secured in storage. This affected four (#11, #14, #15, and #30) of four residents reviewed for medication storage. The facility census was 58. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 6 of 7 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 366142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Run Care Center 3399 Mill Run Drive Hilliard, OH 43026 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #30 revealed an admission date of 04/28/21. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, concussion without loss of consciousness, congestive heart failure, solitary pulmonary nodule, history of falling, intervertebral disc disorders lumbar region, major depressive disorder, anxiety, and dependence on supplemental oxygen. Residents Affected - Some Review of an annual Minimum Data Set (MDS) assessment for Resident #30 dated 04/13/23 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #30 required supervision to limited assistance for activities of daily living (ADLs). Observation on 05/03/23 at 11:04 A.M. of Resident #30 revealed a medication cup containing three pills on the bedside table in Resident #30's bedroom. No staff was observed in the room at the time. Interview on 05/03/23 at 11:09 A.M. with Licensed Practical Nurse (LPN) #144 verified she passed medications to Resident #30 and the resident took the medications. Observation the time of the interview with LPN #144 verified Resident #30 had three pills in a medication cup at the bedside upon entering Resident #30's room. Resident #30 took the medication for LPN #144 at that time. Interview on 05/03/23 at 1:25 P.M. with LPN #144 verified the medications in the medication cup at Resident #30's the bedside included two tablets of the laxative medication Senna-plus and one tablet of the laxative and supplement medication Fibercon. Review of the undated policy titled, Medication Administration, revealed medication is prepared for one resident at the time of administration. Pre-pouring medication is not recommended standard of practice. The person preparing the medication is the only person to administer medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366142 If continuation sheet Page 7 of 7