Inspection·August 22, 2022

F 0550 Resident #47's catheter bag was hanging from the hospital bed, visible from the hallway, and uncovered. Level of Harm - Minimal harm or potential for actual harm On 08/17/22 at 2:52 P.M. interview with State Tested Nursing Assistant (STNA) #180 confirmed Resident #47's catheter bag was uncovered and visible from the hallway. Residents Affected - Few Review of the facility policy titled Resident Privacy: Education & Training, dated 02/18/22 revealed it was the center's policy that each staff member must be trained on and acknowledge the Resident's [NAME] of Rights with regards to privacy Review of the facility undated Resident's [NAME] of Rights revealed the residents had a right to be treated with courtesy and respect and full recognition of dignity and individuality. 2. Review of the medical record for Resident #165 revealed an admission date of 08/04/22 with medical diagnoses including acute cystitis without hematuria, retention of urine, urinary tract infection, hypokalemia, hypomagnesemia and edema. A current physician's order, dated 08/05/22 revealed Resident #165 had orders to empty Foley catheter bag every shift, complete Foley catheter care every shift with instructions to cleanse with soap and water and then rinse, change Foley catheter and bag as a closed system as needed, and change Foley catheter as needed with a size 16 inch French Foley catheter as a closed system. Review of the care plan, dated 08/05/22 revealed Resident #165 had a Foley catheter due to a diagnosis of retention of urine. Interventions included change catheter as a closed system as ordered, empty Foley bag every shift and as needed per treatment plan, encourage fluids, Foley catheter and peri care per order or facility policy, monitor for signs and symptoms of infection, monitor intake and output as indicated, notify physician and responsible party of concerns and document, and size 16 french Foley catheter as per order. Review of the MDS 3.0 assessment, dated 08/10/22 revealed Resident #165 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment revealed the resident required limited to extensive assistance from one to two staff to complete activities of daily living (ADL) care and had an indwelling catheter in place. On 08/16/22 at 9:39 A.M. observation from the hallway revealed Resident #165's catheter bag was hanging from the hospital bed, visible from the hallway, and was uncovered. On 08/17/22 at 10:27 A.M. observation from the hallway revealed Resident #165 was sitting in chair just inside the room door. Resident #165's catheter bag was observed hanging from the trash can, covered with a white pillowcase laid over top of it. On 08/17/22 at 2:50 P.M. Resident #165's catheter bag was observed hanging from the hospital bed, visible from the hallway, and uncovered. Interview with the resident at the time of the observation revealed therapy staff had covered the catheter bag today with a pillowcase and that was the first time it had ever been covered with anything. Resident #165 stated, it is a little embarrassing to walk around with it. Resident #165 stated she had gone to an outside appointment yesterday and carried the urinary drainage bag under her arm, trying to hide it. Resident #165 stated she would like for the catheter bag to be covered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 2 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/17/22 at 2:52 P.M. interview with STNA #180 confirmed Resident #165's catheter bag was visible from the hallway and uncovered. Review of the facility policy titled Resident Privacy: Education & Training, dated 02/18/22 revealed it was the center's policy that each staff member must be trained on and acknowledge the Resident's [NAME] of Rights with regards to privacy Review of the facility undated Resident's [NAME] of Rights revealed the residents had a right to be treated with courtesy and respect and full recognition of dignity and individuality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 3 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on record review, beneficiary notice worksheet review and interview the facility failed to provide an Advanced Beneficiary Notice (ABN) to Resident #315, prior to the resident being cut from Medicare part A therapy services and remaining in the facility. This affected one resident (#315) of one resident reviewed for beneficiary notices who had remained in the facility after being cut from services. Residents Affected - Few Findings Include: Review of the facility beneficiary notice worksheet revealed Resident #315 was the only resident who had been cut from Medicare part A therapy services and remained in the facility in the last six months. Review of the medical record for Resident #315 revealed an admission date of 07/30/22 with diagnoses including wedge compression fracture of T11-T12 vertebra, lower back pain, dyspnea, repeated falls, other spondylosis of the lumbar region, muscle wasting and atrophy and muscle weakness. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review for Resident #315 revealed Medicare Part A skilled services episode started on 07/30/22 (admission). The last covered day for Medicare Part A services was 08/17/22 due to managed care termination. The form noted Resident #315 was scheduled to be discharged to the facility's Assisted Living on 08/18/22 but the resident and family decided to have Resident #315 remain in the Skilled Nursing Facility (SNF) the day after the Notice of Medicare Non-Coverage (NOMNC) was issued, 08/16/22. An ABN was not provided to Resident #315. On 08/18/22 at 10:35 A.M. interview with the Administrator confirmed Resident #315 was not provided with an ABN notice and remained in the facility. A facility policy was requested at the time of the survey for review. No policy was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 4 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on personnel file review, facility policy and procedure review and interview the facility failed to implement their abuse policy and procedure to ensure new hire reference checks were completed upon hire as part of the facility screening process. This had the potential to affect all 61 residents residing in the facility. Residents Affected - Many Findings Include: Review of the following employee personnel files revealed reference checks were either not completed, not completed timely, or had no date to support when the reference check was completed: The Director of Nursing (DON) was hired on 12/29/21. Review of the employee's personnel file revealed no evidence reference checks were completed until 02/16/22. Admissions Director (AD) #32 was hired on 11/08/21. Review of the employee's personnel file revealed she only had one reference check completed and it was undated. In addition, the reference check only mentioned AD #32 was a referral from an existing employee and was asked to come work at the facility; there was no attempt to answer any of the questions on the reference check form. The Administrator was hired on 11/08/21. Review of the employee's personnel file revealed two undated reference checks. Housekeeping Staff #36 was hired on 10/28/21. Review of the employee's personnel file revealed one undated reference check that stated she was referred by another person, but there was no attempt to answer any of the questions on the reference check form. Social Services Coordinator #122 was hired on 02/21/22. Review of the employee's personnel file revealed one undated reference check that stated she was referred by another person, but there was no attempt to answer any of the questions on the reference check form. Licensed Practical Nurse #52 was hired on 10/24/21. There was no evidence any reference checks were completed for the employee. On 08/18/22 at 10:45 A.M. interview with Regional Human Resources Director (HR) #500 confirmed the above findings and lack of evidence of refernce checks being completed upon hire for all staff. HR #500 revealed there should be an attempt to have all reference checks completed prior to hiring anyone to the facility and confirmed there should be dates on the reference checks to identify when they were attempted/completed. Review of facility Abuse policy, dated November 2020 revealed the facility would attempt to obtain information from previous or current employers for all employees upon hire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 5 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #31 was admitted to the facility on [DATE] with diagnoses including respiratory failure, acute kidney failure, hypertension, cerebral infarction, hemiplegia, dysphagia, visual deficit, cerebral atherosclerosis, bradycardia, hyperlipidemia, transient cerebral ischemic attack, dementia, peripheral vascular disease, chronic kidney disease, hydronephrosis, retention of urine, polyneuropathy, weakness and age related cataract. Review of Resident #31 medical record revealed the resident was discharged to the hospital on [DATE]. The facility provided a written copy of the bed hold notice to the resident's representative via certified mail. The bed hold notice was dated 03/21/22, but there was no date on the certified mail form as to when it was sent. Also, there was no documentation on the bed hold notice form as to how many bed hold days were remaining, since the resident received Medicaid benefits. Review of the MDS 3.0 assessment, dated 07/10/22 revealed the resident had cognitive impairment. On 08/18/22 at 10:30 A.M. interview with Administrator confirmed the number of bed hold days remaining was not provided on bed hold notice. 3. Resident #64 was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, acute kidney injury, hypokalemia, traumatic hemorrhage cerebral, non-traumatic intracranial hemorrhage, unspecified falls, atrial fibrillation, type II diabetes, hyperlipidemia, hypertension, hemiplegia, unspecified injury of head, chronic kidney disease, restlessness and agitation, anxiety disorder, gout, and pain. Review of the MDS 3.0 assessment, dated 07/05/22 revealed the resident was cognitively intact. Review of Resident #64's medical record revealed the resident was discharged to the hospital on [DATE]. Within her medical records, there was no evidence to support a bed hold notice had been given. Resident #64 had Medicare benefits, and a bed hold notice should have been provided at the time of discharge to the hospital. Review of facility email communication regarding Resident #64's discharge to the hospital, dated 07/11/22, revealed Admissions Director #32 stated Resident #64 was in neuro intensive care unit (ICU) and most likely going on hospice, per her son. There was no documentation to support bed hold information had been discussed or that the resident representative had been given a written copy of the bed hold notice at the time of discharge. On 08/18/22 at 9:07 A.M. interview with the Administrator revealed the facility did not provide a bed hold notice to Resident #64 or family because she was on Medicare. Review of facility Bed Hold Agreement policy, dated March 2021 revealed it was the facility policy to provide guidance regarding the facility bed hold. Upon discharge, the facility would attempt to review the notice of bed hold with the resident and/or his/her Legal Representative within 24 hours and/or next business day to re-confirm/affirm the bed hold decisions made upon admission. If Medicaid, and if the used bed hold days exceeded the maximum allowable, the resident and/or Legal Representative may choose to pay privately to continue to hold the bed at their discretion. The facility would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 6 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also attempt to provide/send written notice within 24 hours and/or the next business day via certified mail or email the decision made pertaining the bed hold agreement as outlined in the noticed of bed hold. Based on record review, facility policy and procedure review and interview the facility failed to ensure all required information was included on bed hold notices issued to Resident #31, Resident #33, and Resident #64 who experienced hospitalizations. This affected three residents (#31, #33 and #64) of three residents reviewed for hospitalization. Findings Include: 1. Review of the medical record for Resident #33 revealed an admission date of 04/07/22 and a re-admission date on 05/18/22. Resident #33 had diagnoses including encephalopathy, sepsis, other intestinal obstruction, bacteremia, type II diabetes mellitus, Alzheimer's Disease, altered mental status, and urinary tract infection. Resident #33's payor source was Medicaid. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/11/22 revealed Resident #33 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of five out of 15. The assessment revealed Resident #33 required extensive assistance from one staff to complete activities of daily living (ADL) care. Review of a progress note, dated 08/05/22 at 2:34 P.M. revealed the Certified Nurse Practitioner (CNP) had visited Resident #33 in the morning and noted abnormal lab results and an elevated white blood cell count. Resident #33 refused to eat and was more fatigued than usual. A new order was received to send the resident to the hospital for further evaluation. Resident #33's daughter was notified. Review of the Transfer Notice, dated 08/05/22 revealed Resident #33 was sent to the hospital due to an elevated white blood cell count and altered mental status. Review of the Notice of Bed Hold When Leaving the Facility dated 08/05/22 revealed the number of bed hold days Resident #33 had remaining was not included on the bed hold notice. On 08/18/22 at 10:30 A.M. interview with the Administrator confirmed the bed hold notice did not include the number of bed hold days Resident #33 had remaining. Review of the facility policy titled Bed Hold Agreement, revised 05/2020 revealed upon a discharge, the center would attempt to review the Notice of Bed Hold with the resident and/or his or her Legal Representative within 24 hours and/or the next business day to affirm the bed hold decisions made upon admission. If Medicaid, and if the used bed hold days exceed the maximum allowable, the resident and/or his or her Legal Representative may choose to pay privately to continue to hold the bed at their discretion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 7 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 observation, record review and interview the facility failed to ensure Resident #26, who required extensive assistance from staff for personal hygiene received showers as scheduled. This affected one resident (#26) of one resident reviewed for activities of daily living. Residents Affected - Few Findings Include: Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, severe morbid obesity, chronic obstructive pulmonary disease (COPD), diabetes, heart failure peripheral vascular disease, depression, pacemaker, atrial fibrillation and lymphedema. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/07/22 revealed the resident was moderately cognitively impaired. The assessment revealed the resident was totally dependent on two or more staff members for bed mobility, transfers and toilet use, and required extensive assistance from two or more staff members for dressing and personal hygiene. Record review revealed a plan of care reflecting the resident would refuse incontinence care, ACE wraps, to get out of bed, diabetic shoes, medications, meals, linen changes and activities of daily living (ADL) care. Interventions included to notify physician for change in condition, snacks and alternatives to be offered, staff to assist with placement of proper shoes, assist with warming up trays when resident was ready to eat, provide education about importance of letting staff assist with incontinence care, staff to re-approach resident if resident refused care, and staff to encourage resident to toilet. Review of the facility shower schedule revealed the resident was to receive a shower every Tuesday, Thursday and Sunday. Review of the shower sheets from May to August 2022 revealed baths were provided to the resident on 05/12/22, 05/24/22, 05/25/22, 05/31/22, 06/02/22, 06/07/22, 07/04/22, 07/06/22, 07/28/22, 08/02/22, and 08/09/22. The resident was hospitalized from [DATE] to 06/28/22. In addition, the facility provided documentation the resident had refused showers on 05/17/22, 05/19/22, 07/26/22, 08/04/22, 08/11/22 and 08/16/22. Record review and review of the calendar revealed the resident should have received showers on 05/15/22, 05/22/22, 05/29/22 06/05/22. 06/09/22, 06/12/22, 06/30/22, 07/10/22, 07/12/22, 07/14/22, 07/17/22, 07/19/22, 07/21/22, 07/24/22, 07/31/22, 08/07/22 and 08/14/22. However, there was no evidence the shower was provided as scheduled on these dates or that the resident had refused. On 08/16/22 at 12:36 P.M. and 4:11 P.M. Resident #26 was observed to have hair that appeared greasy. On 08/18/22 at 1:30 P.M. interview with the Director of Nursing verified there was no evidence Resident #26 had received showers as scheduled on the date noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 8 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a comprehensive and individualized range of motion program for Resident #50 who was assessed to have limitations in range of motion. This affected one resident (#50) of one resident reviewed for range of motion. Findings Include: Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, aphasia, hemiplegia, encephalopathy, diabetes, and anxiety. A physical therapy evaluation, dated 06/07/21 revealed the resident appeared to be at his baseline with all functional mobility and activities and daily living. Review of the quarterly Minimum Data Set (MDS) assessment,dated 08/02/22 revealed the resident had intact cognition, required extensive assistance fro two or more staff members for bed mobility, and was totally dependent on two or more staff members for dressing and personal hygiene. The assessment revealed the resident had functional limitation in range of motion in the upper and lower extremities on one side. Record review revealed no evidence the functional limitation in range of motion to the resident's upper and lower extremities on one side was care planned or evidence the resident was evaluated and provided any type of restorative nursing range of motion services to maintain, improve or prevent decline of functional mobility. On 08/18/22 at 2:03 P.M. interview with the Corporate Registered Nurse verified the facility had not developed or implemented any type of services to address the resident's range of motion limitations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 9 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure fall interventions were in place to reduce the risk of falls for Resident #21 as care planned. This affected one resident (#21) of three residents reviewed for accidents. Findings Include: Review of the medical record for Resident #21 revealed an admission date on 12/21/18 with diagnoses including dementia with behavioral disturbance, cerebral infarction (stroke), chronic kidney disease, and unspecified protein-calorie malnutrition. Review of the care plan, dated 10/07/20 revealed Resident #21 was at risk for falls due to weakness, limited mobility, cognitive impairment, and impaired safety awareness. Interventions included anticipate needs, assess for fall risk on admission, call light within reach, bright color tape to call light as sensory reminder, pad style call light, night light to the left side of the bed, and body pillow to the right side of the bed, therapy evaluation for a new wheelchair, defined perimeter mattress (DPM) (point to point), drop seat and busy blanket, self-locking wheelchair, place resident to bed after dinner, bed against the wall to enhance living space, non-skid strips beside bed, Dycem (sticky tape-like substance) to wheelchair, pad wheelchair where foot rest attaches, leave door to room open, listen to what the resident was communicating verbally and nonverbally, orient to time, place, daily and as needed only if it calms the resident, provide a safe and structured environment by providing care and activities in the same way and at the same time, provide a clock in the room, and provide name on the door. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/02/22 revealed Resident #21 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of five out of 15. The assessment revealed the resident required extensive assistance from one to two staff to complete activities of daily living (ADLs), including locomotion. The assessment revealed Resident #21 used a wheelchair and no falls were reported since admission, readmission or the prior assessment on the assessment. Review of the Fall Risk Assessment, dated 07/13/22 revealed Resident #21 was high risk for falls. On 08/17/22 at 10:21 A.M. Resident #21 was observed in her room sitting up in her wheelchair next to her bed. The bed had been stripped of sheets and bedding. At the time of the observation, fall interventions (per the plan of care) not observed to be in place included a body pillow, bright colored tape on the call light, a night light to either side of the bed, and a pad style call light. On 08/17/22 at 6:35 P.M. Resident #21 was observed in her room laying in her hospital bed. Fall interventions not in place (per the plan of care) revealed a body pillow was not in place on the right side of the bed, a night light was not in place on either side of the bed, a pad style call light was not in place (a push call light had been placed within the resident's reach), no bright colored tape had been placed on the call light for a sensory reminder as per the resident's care plan. On 08/17/22 at 6:44 P.M. interview with Registered Nurse (RN) #172 confirmed the above fall interventions were not in place for Resident #21 and were indicated on the resident's current care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 10 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Accident/Incident-Prevention/Fall Risk, revised 07/31/14 revealed patients/residents identified as a fall risk would have proactive interventions implemented upon admission. Interventions would be reviewed and updated as needed per the individual needs of our patients/residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 11 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure interventions were in place to decrease the risk of urinary tract infections associated with the use of indwelling urinary catheters for Resident #31. This affected one resident (#31) of three residents review for urinary catheters. Findings Include: Record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including respiratory failure, acute kidney failure, hypertension, cerebral infarction, hemiplegia, dysphagia, visual deficit, cerebral atherosclerosis, bradycardia, hyperlipidemia, transient cerebral ischemic attack, dementia, peripheral vascular disease, chronic kidney disease, hydronephrosis, retention of urine, polyneuropathy, weakness, and age related cataract. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/10/22 revealed the resident was cognitively impaired. Record review revealed Resident #31 had an indwelling urinary catheter. A plan of care related to the catheter revealed an intervention to monitor for signs/symptoms of infection. On 08/16/22 at 9:20 A.M. and 08/17/22 at 9:55 A.M. Resident #31 was observed in bed with the bed in a low position. The resident's urinary catheter drainage bag was observed uncovered and lying directly on the ground. On 08/17/22 at 2:53 P.M. Resident #31 was observed in the common living area, sitting in his wheelchair. The resident's urinary catheter tubing was observed underneath the seat of the chair, directly touching the ground. On 08/17/22 at 2:54 P.M. interview with Registered Nurse (RN) #172 confirmed Resident #31's catheter tubing was touching the ground and indicated it shouldn't be. RN #172 revealed she would take Resident #31 to his room and shorten the tubing so it would not touch the ground as this had the potential to cause a urinary tract infection for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 12 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure weekly weights were obtained as ordered to monitor the nutritional status of Resident #13. This affected one resident (#13) of three residents reviewed for nutrition. Residents Affected - Few Findings Include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including anemia, high blood pressure, malnutrition, anxiety, depression and osteoarthritis. Review of the physician's orders, revealed an order dated 01/31/22 to obtain weekly weights. Review of the weight report from March to August 2022 revealed weights were not obtained weekly as ordered. Weights were only documented as being obtained on 03/07/22, 03/21/22, 04/03/22, 04/04/22, 04/18/22, 04/25/22, 05/02/22, 05/04/22, 05/16/22, 05/23/22, 05/30/22, 06/06/22, 06/13/22, 06/20/22, 06/27/22, 07/11/22 and 07/25/22. The resident was hospitalized from [DATE] to 08/07/22 and refused a weight on 08/08/22. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/11/22 revealed the resident had moderately impaired cognition, required extensive assistance from one staff member for bed mobility, dressing, toilet use and personal hygiene. On 08/18/22 at 9:40 A.M. interview with the Director of Nursing verified weekly weights were not obtained as ordered for Resident #13. Review of the facility policy and procedure titled Weight Management Protocols, dated 04/16/21 revealed all residents were to be weighed upon admission and monthly thereafter, unless more frequent monitoring was ordered by the physician or requested by nursing judgement or clinical nutrition assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 13 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized behavioral health program to address Resident #256's depression diagnosis and anti-depressant medication use. This affected one resident (#256) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #256 revealed an admission date of 08/13/22 with diagnoses including encounter for orthopedic aftercare, alcohol dependence and depression. Review of the baseline plan of care, dated 08/13/22 revealed Resident #256 was to have mental health monitored and a depression screening completed as needed. Review of a progress note, dated 08/14/22 at 12:26 P.M. revealed the resident was admitted to skilled facility with family at bedside, status post back surgery due to narrowing on spinal cord. Past medical history included irregular heart beat, pre-operative cardiovascular exam, alcohol use and episodic confusion. The note revealed the resident was alert and oriented times three today and able to make needs known with some slight confusion. Review of Resident #256's physician's orders, dated August 2022 revealed an order for the anti-depressant medication, Bupropion XL (Buspar) 150 milligrams (mg) one tablet daily for depression. On 08/16/22 at 11:30 A.M. during an interview with Resident #256, the resident became very tearful and started to cry stating I am so depressed, I dont know what to do. On 08/18/22 at 2:00 P.M. interview with the Administrator revealed the facility had not offered or provided any type of psychosocial services or counseling for the resident following admission. On 08/18/22 at 2:30 P.M. interview with the Director of Nursing (DON) revealed nursing staff were to document behavior monitoring for the resident related to the use of medication for depression. The DON revealed there was an area to enter the documentation on the medication administration record (MAR). Review of the MAR from 08/13/22 through 08/18/22 revealed nursing staff were documenting there was no side effects experienced from the anti-depressant medication being administered. However, there was no evidence of target behaviors being monitored or the number of behavior episodes displayed by the resident during this time period. Review of the facility policy titled Medication Management, dated 07/27/21 revealed non-pharmalogical interventions such as behavior modification or social services and their effects were documented as part of the care planning process, and were utilized by the prescriber in assessing the continued need for medication. Psychopharmacological medication were any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders other than antipsychotic and sedative/hypnotic. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 14 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure non-pharmacological interventions were attempted and documented prior to the administration of as needed (PRN) pain medications . This affected three residents (#13, #56 and #60) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings Include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, high blood pressure, malnutrition, anxiety, depression, osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/11/22 revealed the resident had moderately impaired cognition and required extensive assistance from one staff member for bed mobility, dressing, toilet use and personal hygiene. Review of the 08/2022 physician's orders revealed the resident had an order for the narcotic analgesic, Oxycodone HCL five milligrams (mg) every two hours as needed for pain. Review of the plan of care revealed to administer medications as ordered, assess specific methods to calm and soothe, monitor labs, monitor and document behavior, monitor effectiveness and side effects, notify physician/responsible party of any changes in condition and document. Review of the PRN medication administration report revealed the resident received the Oxycodone on the following dates with no evidence of any attempt for non pharmacological interventions prior to the administration of the medication: 05/17/22, 05/18/22, 05/19/22, 05/20/22, 05/23/22, 05/25/22, 05/26/22, 05/27/22, 06/03/22, 06/05/22, 06/06/22, 06/09/22, 06/11/22, 06/13/22, 06/14/22, 06/15/22, 06/17/22, 06/20/22, 06/21/22, 06/23/22, 06/25/22, 06/27/22, 06/28/22, 07/01/22, 07/04/22, 07/05/22, 07/07/22, 07/08/22, 07/09/22, 07/11/22, 07/12/22, 07/14/22, 07/15/22, 07/18/22, 07/31/22, 08/01/22, 08/07/22, 08/08/22, 08/09/22, 08/12/22, 08/13/22, 08/14/22, 08/15/22, 08/16/22 and 08/17/22. On 08/18/22 at 1:10 P.M. interview with the Director of Nursing (DON) verified non pharmacological interventions were not attempted/documented prior to the administration of the Oxycodone as noted above. 2. Review of Resident #56's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, heart failure, thyroid disorder, osteoporosis, dementia, Parkinson's disease, anxiety and depression. Review of the MDS 3.0 assessment, dated 08/11/22 revealed the resident had moderately impaired cognition, she required extensive assistance from two or more staff members for bed mobility and was totally dependent on two or more staff members for transfers, dressing and personal hygiene. Review of the plan of care revealed to administer medications as ordered and observe for side effects, monitor and document behaviors, monitor lab values and notify physician/responsible party of any in condition. Review of the physician's orders for 08/2022 revealed the resident had an order for the narcotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 15 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 analgesic medication Hydrocodone-Acetaminophen 5-325 mg as needed (PRN). Level of Harm - Minimal harm or potential for actual harm Review of the PRN medication administration report revealed the resident received the Hydrocodone-Acetaminophen on the following dates with no evidence of any attempt for non pharmacological interventions prior to the administration of the medication: 05/20/22, 06/11/22, 06/18/22, 06/28/22, 07/11/22, 07/15/22, 07/19/22,07/26/26/22, 07/28/22, 08/01/22. Residents Affected - Few On 08/18/22 at 1:10 P.M. interview with the DON verified non pharmacological interventions were not attempted/documented prior to the administration of the Hydrocodone-Acetaminophen as noted above. 3. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including deep vein thrombosis, neurogenic bladder, diabetes, dementia, quadriplegia, depression, anxiety and traumatic spinal cord dysfunction. Review of the MDS 3.0 assessment, dated 07/24//22 revealed the resident had intact cognition, he required extensive assistance from two or more staff members for bed mobility, extensive assistance from one staff member for dressing, toilet use and personal hygiene and was totally dependent on two or more staff members for transfers. Review of the plan of care revealed to administer medications as ordered and observe for side effects, monitor and document behaviors, monitor lab values and notify physician/responsible party of any in condition. Review of the physician's orders for 08/2022 revealed an order for the pain medication, Tramadol 50 mg every eight hours as needed for pain. Review of the PRN medication administration report revealed the resident received the Tramadol on the following dates with no evidence of any attempt for non pharmacological interventions prior to the administration of the medication: 07/19/22 at 1:42 P.M., 07/23/22 at 4:42 A.M., 07/27/22 at 8:24 P.M., 07/31/22 at 11:32 A.M., 08/14/22 at 9:02 A.M., and 5:23 P.M., 08/15/22 at 9:55 A.M. and 08/17/22 at 8:04 P.M. On 08/18/22 at 1:40 P.M. interview with the Corporate Registered Nurse verified non pharmacological interventions were not attempted/documented prior to the administration of the Tramadol as noted above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 16 of 17 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 366155 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Albany Care Center 5691 Thompson Road Columbus, OH 43230 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy and procedure review and interview the facility failed to ensure an antibiotic for prophylactic treatment of urinary tract infections was justified and necessary for Resident #53. This affected one resident (#53) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of the medical record for Resident #53 revealed an admission date of 10/26/21 with diagnoses including COVID-19, dementia without behavioral disturbance, need for assistance with personal care and adult failure to thrive. Review of Resident #53's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 07 indicating the resident had moderately impaired cognition for daily decision making abilities. The assessment revealed Resident #53 required extensive assistance from two staff members for toilet use and personal hygiene and was frequently incontinent of bowel and bladder. Review of Resident #53's physician's orders revealed an order, dated 05/17/22 for the antibiotic Macrobid 100 milligrams (mg) one capsule daily for prophylaxis for urinary tract infections. On 08/18/22 at 2:00 P.M. interview with the Director of Nursing (DON) revealed Resident #53 was ordered the antibiotic, Macrobid prophylactic for recurring urinary tract infections. Since the order, the medication had been placed on hold multiple times due to Resident #53 developing urinary tract infections which required treatment with a different antibiotic. When asked for justification for the continued use of Macrobid prophylactic, the DON revealed the resident was to see a urologist. An original urology appointment had to be re-scheduled due to transportation issues. The resident currently had COVID-19 which resulted in the urology appointment being placed on hold. The facility was unable to provide evidence the continued use of the antibiotic Macrobid (ordered since May 2022) was justified and warranted for the resident. Review of the facility policy titled Antibiotic Stewardship, dated 10/21/17 revealed it was the centers policy to maintain an antibiotic stewardship program (ASP) with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366155 If continuation sheet Page 17 of 17