Inspection·April 13, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (STNA) #615, who was a bully. Resident #48 stated she told Social Worker (SW) #639 during a care conference last week about STNA #615 and how she made her feel like she was bothering her. Resident #48 stated STNA #615 would stand in the hall, speak loudly, and say things like she technically did not have to answer call lights except for once every two hours, spoke about other residents, would tell her she could do things for herself and not want to help, and was just not friendly. Resident #48 stated she initially thought STNA #615 talked to herself but then she realized she wore ear buds and was on her phone. Resident #48 stated her condition had fortunately improved and she was able to do more for herself and did not ask for help unless necessary because she did not want to encounter STNA #615. Interview on 04/11/23 at 12:10 P.M., with STNA #615 revealed Resident #48 required more assistance when she initially admitted but was doing better and was able to do most things for herself. STNA #615 did not provide any additional pertinent information. Interview on 04/12/23 at 8:03 A.M., with Social Worker (SW) #639 revealed Resident #48 expressed concern last week regarding STNAs making her feel like they did not want to help her. SW #639 stated Resident #48 indicated STNAs would tell her she could do things for herself when she requested assistance. SW #639 stated Resident #48 was apprehensive about reporting her concerns and did not provide any specific staff names. SW #639 stated STNA #615 had a history of customer service concerns and had received education in the past related to her approach with residents. SW #639 stated she did report Resident #48's concerns to the former Director of Nursing (DON) #660 and she believed the concerns were addressed. Interview on 04/12/23 at 8:15 A.M., with the Administrator confirmed Resident #48 expressed concerns related to STNA #615 and her approach with residents. The Administrator stated Resident #48 provided information to former Unit Manager (UM) #700, who followed up with STNA #615. While the Administrator was unaware of any specific concerns related to STNA #615's approach with Resident #48, Resident #48 had reported to UM #700 that STNA #615 spoke loudly in the hall, talked about other residents, stated she was only checking on residents every two hours, and used profanity. The Administrator stated UM #700 provided verbal education to STNA #615. In addition, the Administrator stated there was an active investigation with the union related to the concerns expressed by Resident #48. Review of the policy titled Resident Rights Guidelines, dated July 2022, revealed residents had the right to be treated with dignity and respect and to be treated fairly, courteously, and with respect by all staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 2 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and resident and staff interview, the facility failed to ensure a resident was evaluated for safe use of a motorized wheelchair and provided a foot pedal for the manual wheelchair. This affected one (#5) of one resident reviewed for accommodation of needs. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 05/12/22. Diagnoses included urinary retention, edema, hypothyroidism, muscle weakness, insomnia, idiopathic peripheral autonomic neuropathy, heart failure, osteoarthritis, coronary artery disease, and unsteadiness on feet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, was dependent on two staff for bed mobility and transfers and utilized a wheelchair for mobility. In addition, Resident #5 received Occupational Therapy (OT) from 08/03/22 to 10/06/22. Review of the plan of care initiated 05/13/22 revealed Resident #5 had impaired mobility related to history of right femur fracture, weakness, and right foot drop and needed assistance with transfers and mobility. Interventions included OT, Physical Therapy (PT) and Speech Therapy (ST) as needed. In addition, Resident #5 was at risk for falls related to pain, right foot drop, weakness, and use of assistive device. Interventions included encouraging the use of wheelchairs and PT and OT to evaluate and treat as ordered. Lastly, Resident #5 had basic care needs and preferences for daily routine. Interventions included wheelchair for mobility. Observation and interview on 04/10/23 at 12:05 P.M., with Resident #5 revealed the resident sitting in the doorway of her room. Resident #5 was in a manual wheelchair. Resident #5 stopped the surveyor and inquired if the surveyor could find the foot pedal for her wheelchair. Resident #5's right foot was noted to be hanging, not touching the floor, and no foot pedal was attached to the wheelchair. State Tested Nurse Aide (STNA) #725 approached Resident #5 and assisted the Resident to the dining room for lunch. STNA #725 was observed not to attach a right foot pedal to the wheelchair. Interview on 04/10/23 at 3:15 P.M., with Resident #5 revealed prior to her admission to the facility, she had a power wheelchair. Resident #5 stated the facility took it from her because something was wrong with it, and she never got it back. Resident #5 stated she preferred her power wheelchair because it was easier for her to navigate and move about independently. Interview on 04/13/23 at 10:02 A.M., with Director of Rehabilitation (DOR) #720 revealed Resident #5 admitted to the facility with a power wheelchair. DOR #720 stated, upon admission, the use of a power wheelchair was not appropriate for use due to Resident #5's limited range of motion of the right knee. DOR #720 stated Resident #5's power wheelchair was stored at the facility and, while it was manual, the wheelchair she was using was appropriate. DOR #720 could not recall if Resident #5 had been reassessed to determine if the use of her power wheelchair would be appropriate at this time. DOR #720 stated he was working based off memory of something that occurred about a year ago and did not recall all the specifics. DOR #720 agreed to review Resident #5's treatment history and follow up with the surveyor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 3 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A follow up interview on 04/13/23 at 1:19 P.M., with DOR #720 revealed Resident #5 admitted to the facility in May 2022 for rehabilitation following a fall and right leg fracture. DOR #720 stated it was not safe for Resident #5 to utilize her power wheelchair due to a lack of range of motion of her right knee, noting it was a safety issue because the resident's right foot could not rest on the foot plate. DOR #720 explained the power wheelchair's foot plate did not extend to accommodate Resident #5's lack of range of motion of the right knee. DOR #720 stated Resident #5's power wheelchair was placed upstairs at the facility, and she was provided a manual wheelchair. DOR #720 stated Resident #5 was able to propel her manual wheelchair herself, but preferred to have staff push her. DOR #720 confirmed Resident #5 had not been re-evaluated to determine if she could safely use her power wheelchair and the facility had not explored if the resident could get a new power wheelchair if the one stored at the facility was determined to not be safe or could not be modified to accommodate her needs. DOR #720 stated the therapy department would investigate her power wheelchair if Resident #5 asked, but she had not requested that be done. Event ID: Facility ID: 366192 If continuation sheet Page 4 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to notify the physician when medications were not being administered per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/13/21. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the current orders for Resident #43 revealed orders dated 09/15/22 for the gastrostomy tube patency and placement to be verified with 30 milliliters (ml) of air before each medication administration and feeding and for the gastrostomy tube to be flushed with 30 ml of water before and after medication administration. Orders initiated on 09/16/22, for the diagnosis of hypertension called for amlodipine 10 milligrams (mg) to be administered per gastrostomy tube every morning, hydralazine 50 mg administered per gastrostomy tube three times a day and lisinopril 40 mg administered per gastrostomy tube once a day. Review of the medication administration record for February 2023 revealed lisinopril 40 mg was documented as on hold on 02/21/23 at 5:06 A.M., amlodipine 10 mg was on hold on 02/21/23 at 5:06 A.M. and hydralazine 50 mg was on hold on 02/02/23 at 11:35 A.M., 02/21/23 at 5:06 A.M., 02/22/23 at 12:19 P.M. and on 02/26/23 at 12:05 P.M. and documented as not administered on 02/04/23 at 9:39 A.M. and 02/20/23 at 11:44 A.M. Review of the medication administration record for March 2023 revealed hydralazine 50 mg was on hold on 03/01/23 at 12:45 P.M., 03/12/23 at 5:57 P.M., 03/19/23 at 12:32 P.M. and 5:37 P.M., 03/21/23 at 11:21 A.M., 03/31/23 at 11:27 A.M. and not administered on 03/11/23 at 12:23 P.M., 03/12/23 at 12:21 P.M., 03/23/23 at 12:02 P.M., 03/25/23 at 6:51 P.M. and 03/26/23 at 6:15 P.M. Review of the medication administration record for April 2023 revealed hydralazine 50 mg had not been administered as ordered on 04/11/23 at 11:33 A.M. and 4:16 P.M. Review of the medical record and the medication administration records for February, March and April 2023 remained silent for documentation related to medications being held or not administered and further remained silent for the physician notification related to the medications held or not administered. Interview on 04/12/23 at 3:50 P.M., with the Interim Director of Nursing (DON) verified both the medications were held without physician notification and added the facility policy regarding medication administration was not followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 5 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0580 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Medication Administration, dated May 2019 revealed prescribed medications are ordered and delivered in a timely fashion, if medications are withheld the licensed nurse professional administering the medications shall appropriately mark the electronic medical record and document the reason. The physician shall be notified when the medication is not given, and the physician notification is to be documented in the electronic medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 6 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, resident and staff interviews, the facility failed to ensure residents dependent on staff to provide assistance with captivities of daily living (ADLs) was provided the required assistance. This affected two (#36 and #38) of six residents reviewed for ADLs. The facility census was 55. Residents Affected - Few Findings include: 1. Review of Resident #36's medical record revealed an admission date of 04/21/22. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive heart disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two-person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Review of a plan of care focus area initiated 05/03/22 revealed Resident #36 needed assistance with bathing and hygiene related to restricted mobility, weakness, heart failure, shortness of breath, COPD, and dementia. Interventions included assisting with bathing body parts resident is unable to do, encouraging and assisting in maintenance of good grooming and hygiene, and verbal reminders and verbal cues while bathing, dressing, and grooming. Observation on 04/11/23 at 4:41 P.M., revealed Resident #36 was in bed. Resident #36's meal tray was sitting on the bedside table, out of reach of the resident. The dinner plate had a cover over it. Observation on 04/11/23 at 5:00 P.M., revealed Resident #36's meal tray remained on the bedside table, to the left of the resident, with the plate still covered. Resident #36 was observed to reach with her left hand to try to pull the bedside table toward her. Resident #36 was unable to pull the table to her. Observation on 04/11/23 at 5:25 P.M., revealed Resident #36's meal tray was still on the bedside table, with the cover on the plate, and out of reach of the resident. Licensed Practical Nurse (LPN) #659 entered the room to check on the resident and provide water. Interview of LPN #659, at the time of the observation, confirmed Resident #36 was able to feed herself after receiving assistance with meal set up. LPN #659 verified Resident #36 could not reach her dinner meal. LPN #659 removed the cover from the dinner plate and moved the table to Resident #36, who picked up her hamburger and began eating. Observation on 04/12/23 at 7:10 A.M., revealed breakfast meal trays arrived at the B Hall, the hall Resident #36 resided on. Resident #36 was observed to be sleeping in her bed. Observation on 04/12/23 at 11:18 A.M., revealed Resident #36 laying sideways in her bed, with her head resting on the right-side bed rail. Interview of Resident #36, at the time of the observation, revealed she was not comfortable in bed. Resident #36 raised her right arm and oatmeal was noted on the underside of the resident's right arm and on the right side of her gown, sheets, and blankets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 7 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #36 stated she dropped her bowl of oatmeal during breakfast this morning. Resident #36 stated her adult brief was wet and she believed the last time staff was in her room was around 9:00 A.M. Resident #36 had her blanket pulled down to her thighs and her gown was pulled up around her waist. Observation of Resident #36's brief revealed the brief was saturated with a yellow discoloration. Interview on 04/12/23 at 11:42 A.M., of State Tested Nurse Aide (STNA) #615 revealed she last provided care to Resident #36 around 6:45 A.M. STNA #615 stated personal care was typically provided to Resident #36 after meals because of potential spills. Observation of Resident #36, with STNA #615, at the time of the interview verified Resident #36's brief was saturated with urine and the resident had oatmeal on her right arm and on her gown, sheets, and blanket. STNA #615 stated she had been in to reposition Resident #36 throughout the morning but denied Resident #36 had been soiled and she had not noticed the oatmeal spilled on the resident and her bedding. STNA #615 stated she picked up Resident #36's breakfast meal tray around 8:30 A.M. and verified Resident #36 would have had the oatmeal on her from that time. Observation on 04/13/23 at 9:41 A.M., of Resident #36 revealed the resident in bed. Resident #36's fingernails were observed to be long, with debris under the nails. Interview of Resident #36, at the time of the observation, revealed she preferred to have her fingernails short. Interview on 04/01/23 at 9:44 A.M., of STNA #730 verified Resident #36's fingernails were long and had debris under them. STNA #730 stated she believed only the podiatrist could cut fingernails because of diabetes. Related to the debris under the fingernails, STNA #730 stated she did just eat breakfast. 2. Review of Resident #38's medical record revealed an admission date of 07/05/22. Diagnoses included dementia, osteoarthritis, cardiomegaly, essential hypertension, heart failure, hypertensive heart disease, mild cognitive impairment, history of falling, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired and required extensive one-person physical assistance with personal hygiene. In addition, Resident #38 did not reject care during the look back period. Review of a plan of care focus area initiated 07/05/22 revealed Resident #38 needed assistance with bathing and hygiene related to congestive heart failure and weakness. Interventions included encouraging and assisting in maintenance of good grooming and dressing. Observation on 04/11/23 at 2:46 P.M., revealed Resident #38's fingernails were long, with debris under the nails. Interview on 04/11/23 at 2:46 P.M., of STNA #671 verified Resident #38's fingernails were long, with debris under the nails. STNA #671 stated she was an agency STNA and did not know Resident #38. Interview on 04/11/23 at 3:17 P.M., of LPN #659 revealed Resident #38 did not like to get out of bed but she would allow care to be provided. LPN #659 stated Resident #38 did not refuse care. LPN #659 verified Resident #38's fingernails were long and dirty and stated she would trim them today. Observation on 04/12/23 at 7:13 A.M. revealed Resident #38's fingernails remained dirty and untrimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 8 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and review of policy, the facility failed to ensure activities of interest were provided to residents who stayed in their room. This affected two (#36 and #43) of three residents reviewed for activities. The facility census was 55. Residents Affected - Few Findings include: 1. Review of Resident #36's medical record revealed an admission date of 04/21/22. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Review of a plan of care focus area initiated 03/24/23 revealed Resident #36 was a long term resident of the facility and able to make her needs and preferences known. The resident stated she had no interest in activities while at the facility. Interventions included place an enlarged monthly activities calendar in the room to promote daily activities, encourage resident to engage in activities of interest daily, assist with activities as needed, and staff will visit 1:1 as tolerated. Further review of a plan of care focus area initiated 04/11/23 revealed Resident #36 presented with impaired cognition. Interventions included daily orientation to facility routines and activity schedule, environmental cues to stimulate memory, provide consistent physical environment and daily routine, and avoid demands for abstract thinking. Observations on 04/10/23 at 1:41 P.M.; 04/11/23 at 2:54 P.M.' 4:27 P.M., and 5:25 P.M.; 04/12/23 at 7:10 A.M., 11:18 A.M., 3:55 P.M., and 4:22 P.M.; and on 04/13/23 at 9:41 A.M. revealed Resident #36 in bed with the television on during each of the observations. Interview on 04/12/23 at 4:22 P.M., with State Tested Nurse Aide (STNA) #632 revealed Resident #36 remained in bed all of the time. STNA #632 stated day shift got Resident #36 out of bed once, about one month ago, but the resident screamed the entire time because she was in pain. Resident #36 was put to bed and had not been up again since. STNA #632 stated it was her understanding Resident #36 did not want to get out of bed and participate in activities or go to the dining room, but she herself had not asked Resident #36. STNA #632 stated Resident #36 laid in bed all day, with staff checking on her about every two hours, and had no other involvement in facility activities. Observation on 04/13/23 at 9:41 A.M., of Resident #36's room revealed an activity calendar hanging on a bulletin board on the wall immediately to the left upon entrance to the room. The bulletin board and calendar were located behind the head of Resident #36's bed, which was not visible to Resident #36. Interview of Resident #36 confirmed she did not get out of bed, participate in facility activities, or go to the dining room for any meals. Resident #36 stated All I do is lay here in this bed. Resident #36 stated she would like to get up and do something but was not aware of the facility activities. Resident #36 stated she assumed there was a physician order requiring her to stay in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 9 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/13/23 at 9:45 A.M. with STNA #645 revealed Resident #36 remained in bed all of the time, with no active engagement or participation in activities or dining. STNA #645 stated she was not sure why Resident #36 never got up to go to activities or the dining room, stating she was told Resident #36 got up one time and yelled because she was in pain and staff never got her up again. STNA #645 confirmed she had never approached Resident #36 about getting up to go to the dining room or participate in any other facility activities and the resident laid in bed all day with the television on. Interview on 04/13/23 at 2:23 P.M., with Activities Assistant (AA) #699 revealed the facility used to have specific programming for residents with dementia, but it was not currently in use. AA #699 confirmed Resident #36 did not attend any activities and stayed in her room all of the time. While she attempted to visit with Resident #36 daily, that was not possible and was more likely to be two to three visits each week. In addition, if Resident #36 was sleeping at the time of the visit, AA #699 did not return so visits were sometimes less frequent. AA #699 stated during their visits, Resident #36 would speak of past interests, liked to get her fingernails done, and do crafts. Additionally, AA #699 stated Resident #36 expressed an interest in going outside, but that activity had not occurred. AA #699 confirmed the activity calendar was hanging behind Resident #36, out of her view, and unless someone told her daily what activities were available, she would be unaware. AA #699 confirmed Resident #36's plan of care was not individualized and did not identify areas of interest to assist in keeping Resident #36 engaged. 2. Review of the medical record for Resident #43 revealed an admission date of 06/13/21. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was totally dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the care plan revised 01/12/23 revealed Resident #43 was a long-term resident and is unable to make needs and preferences known. The goal for Resident #43 revealed the resident will engage in activities of interest as tolerates and the resident will accept one on one visits daily. Interventions included staff will place an enlarged monthly activity calendar in the room to promote daily activities, staff will encourage the resident to engage in activities of interest daily and will offer assistance with activities as needed, staff will visit one on one as tolerated. Review of the preferred activities for Resident #43 revealed music, television and being outdoors. Observations on 04/11/23 at 7:15 A.M. of Resident #43 laid in bed looking out the window. Additional observations on 04/11/23 at 3:53 P.M. and on 04/12/23 at 8:01 A.M. and 11:00 A.M. and 3:30 P.M. and on 04/13/23 at 8:56 A.M. revealed Resident #43 was in bed with the television on during each observation. Interview on 04/13/23 at 11:00 A.M., with the Interim Director of Nursing (DON) verified Resident #43 had not been assisted out of bed in some time and is unsure of why the resident has not been assisted out of bed daily as the resident should be. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 10 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/13/23 at 2:35 P.M., with AA #699 revealed the facility used to have specific programming for residents with dementia, but it was not currently in use. AA #699 confirmed Resident #43 did not attend any activities and stayed in her room all of the time. While she attempted to visit with Resident #43 daily, that was not possible and was more likely to be two to three visits each week. AA #699 stated during their visits, staff would sit with Resident #43 while watching television. Additionally, AA #699 stated Resident #43 expressed an interest in going outside, but that activity had not occurred. AA #699 confirmed the activity calendar was hanging behind Resident #43, out of her view, and unless someone told her daily what activities were available, she would be unaware. AA #699 confirmed Resident #43's plan of care was not individualized and did not identify areas of interest to assist in keeping Resident #43 engaged. Review of the policy titled Programming for Resident with Cognitive Impairments and Other Special Needs, revised March 2012, revealed activity programs were provided for the maintenance and enhancement of each resident's quality of life while promoting physical, cognitive and emotional health. The facility shall offer meaningful programs for residents with cognitive impairments that use reality and sensory awareness techniques. In addition, the activity department coordinates care planning with nursing and other members of the Interdisciplinary Team to develop and effective approach for meeting special activity needs of residents. Lastly, environmental modifications are implemented, as needed, to provide the least restrictive environment to enable activity participation while maintaining dignity. The focus should be on the resident's abilities, not disabilities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 11 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and resident interview, the facility failed to provide adequate care and treatment for a resident experiencing edema. This affected one (#17) of 16 residents reviewed for quality of care and treatment. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 10/18/19 and a readmission date of 01/10/23. Diagnoses included chronic kidney disease, heart failure, hypertension (HTN), osteoarthritis, glaucoma, congestive heart failure (CHF), and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set up assistance with activities of daily living (ADLs) and was on a therapeutic diet. Review of the plan of care initiated 01/10/23 revealed Resident #17 was on diuretic therapy related to HTN and CHF. Interventions included administering medications per order. Review of current physician orders for April 2023 revealed Resident #17 was prescribed spironolactone (diuretic) 25 milligram (mg) tablet two times daily. Additional review revealed no physician orders for compression stockings. Review of a physician progress note dated 04/06/23 revealed Resident #17 had leg swelling, noted to be a chronic condition, and was no longer on lasix. Resident #17 was encouraged to wear compression stockings every day. Review of an Occupational Therapy (OT) progress note dated 04/12/23 revealed Resident #17 required maximum assistance to apply compression stockings. Interview on 04/10/23 at 12:13 P.M., with Resident #17 revealed compression stockings were to be applied in the morning and removed at night. Observation at the time of the interview revealed Resident #17 was not wearing compression stockings and swelling was noted to bilateral lower extremities. Resident #17 stated staff were to assist with applying compression stocking, but it was not being done. Interview on 04/11/23 at 3:18 P.M., with Licensed Practical Nurse (LPN) #659 revealed Resident #17 had an order for a diuretic but did not have an order for compression stockings. LPN #659 stated she had never known Resident #17 to wear compression stockings. Observation on 04/11/23 at 3:22 P.M., revealed Resident #17 walking down the hall. Swelling was noted to the Resident's bilateral lower extremities. Resident #17 was not observed to be wearing compression stockings and a pair of compression stockings were observed to be folded and laying at the foot of the Resident's bed. A follow up interview on 04/12/23 at 11:13 A.M., with Resident #17 revealed OT assisted her with applying compression stockings this morning. Resident #17 stated her daughter brought the compression stockings in because of the swelling in her legs and her physician told her last week to wear them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 12 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/12/23 4:18 P.M., with State Tested Nurse Aide (STNA) #632 confirmed Resident #17's daughter had brought in compression stockings for Resident #17. STNA #632 confirmed Resident #17 had not been wearing them and she did not believe there was an order for them. Observation on 04/13/23 at 8:43 A.M., with LPN #631, confirmed Resident #17 had right leg edema rated at +1 (mild pitting, slight indentation) on the left lower extremity and +2 (moderate pitting, 1/4-to-1/2-inch indentation) on the right lower extremity. LPN #631 stated Resident #17 had bilateral swelling since her admission and, to her knowledge, had never worn compression stocking. During the observation, Resident #17 reiterated that the physician told her last week to wear compression stockings every day. LPN #631 stated she would follow up with the physician. A follow up interview on 04/13/23 at 9:48 A.M., with LPN #631 revealed she spoke with the physician regarding compression stockings for Resident #17. LPN #631 confirmed Resident #17 should have had an order for them, however, the physician stated because Resident #17 had compression stockings in her room, the physician thought there was already an order and had not confirmed an order existed. LPN #631 verified a new order would be entered today for Resident #17 to have compression stockings applied in the morning and removed at night. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 13 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 medical record review, observation, resident's friend interview, resident interview, and staff interview, the facility failed to ensure residents received timely incontinence care. This affected one (#36) of one residents reviewed for incontinence care. The facility census was 55. Findings include: Review of Resident #36's medical record revealed an admission date of 04/21/22. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure, pulmonary hypertension, atrial fibrillation, chronic obstructive pulmonary disease, rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. Additionally, Resident #36 was always incontinent of bowel and bladder. Review of a plan of care focus area initiated 05/03/22 revealed Resident #36 had urinary incontinence related to restricted mobility, dementia, and weakness. Interventions included provide toileting assistance as needed, provide adult incontinence products, and monitor for incontinence frequently. Interview on 04/11/23 at 2:54 P.M., with Resident #36's friend revealed she had been visiting with the resident for at least 30 minutes and Resident #36 had indicated to her upon her arrival that she had been incontinent and needed changed. Interview of Resident #36 at the time revealed she required assistance with incontinence care and it had likely been two or more hours since she was last checked on by staff. Follow up interview on 04/11/23 at 4:27 P.M., with Resident #36 revealed staff still had not been in her room to check on her and she required incontinence care. Interview on 04/11/23 at 4:28 P.M., with State Tested Nurse Aide (STNA) #671 revealed her shift began at 2:00 P.M. STNA #671 verified she had not provided care to Resident #36 since the start of her shift. STNA #671 asked What's wrong with her? The surveyor indicated Resident #36 required incontinence care. STNA #671 stated she needed to pass dinner meal trays and would change Resident #36 when she was finished. Continued observations on 04/11/23 from 4:41 P.M. through 5:25 P.M., revealed STNA #671 continued to pass dinner meal trays and Resident #36 had not received incontinence care. Observation on 04/11/23 at 5:25 P.M., revealed Licensed Practical Nurse (LPN) #659 entered Resident #36's room to check on the Resident and provide water. Interview with LPN #659 revealed briefs usually had a blue line when they were wet. LPN #659 verified the brief did not have a blue line. LPN #659 poked the brief, which was firm to the touch, and verified Resident #36's brief was saturated with urine. LPN #659 covered Resident #36 with a sheet and blanket, moved the over the bed table with the dinner meal tray over to the resident and left the room without providing incontinence care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 14 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Observation on 04/12/23 at 11:18 A.M., revealed Resident #36 laying in bed. Resident #36 stated she had been incontinent and needed changed. Resident #36's blankets were pulled down to her thighs and her gown was around her waste. Resident #36's brief was exposed and a yellow discoloration on the brief was noted. Interview on 04/12/23 at 11:42 A.M., with STNA #615 revealed residents should be checked and changed at least every two hours. STNA #615 stated she last provided incontinence care to Resident #36 around 6:45 A.M. STNA #615 verified Resident #36's brief was saturated with urine and confirmed Resident #36 would not utilize her call light to request assistance if needed. Event ID: Facility ID: 366192 If continuation sheet Page 15 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 medical record review, observation, resident and staff interviews, review of resident's meal ticket and review of policy, the facility failed to ensure a resident's physician ordered therapeutic diet was provided as ordered. This affected one (#17) of two residents reviewed for nutrition. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #17's medical record revealed an admission date of 10/18/19 and a readmission date of 01/10/23. Diagnoses included chronic kidney disease, heart failure, hypertension (HTN), osteoarthritis, glaucoma, congestive heart failure (CHF), and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set up assistance with activities of daily living (ADLs) and was on a therapeutic diet. Review of the plan of care dated 01/23/23 revealed Resident #17 was at risk for altered nutrition and hydration related to advanced age, CHF, and diuretic treatment. Avoid hot dogs, sausage, bacon and ham. Interventions included diet as ordered. Additional review of the plan of care revealed Resident #17 had potential for fluid imbalance and activity tolerance related to CHF. Interventions included diet per order. Review of a Nutrition assessment dated [DATE] revealed Resident #17 was on a no added salt, regular diet with thin liquids and no bacon, ham, hot dogs, and sausage. Review of current physician orders for April 2023 revealed Resident #17 was ordered a no added salt, regular diet with thin liquids, no ham, bacon, sausage, or hot dogs. Interview on 04/10/23 at 11:25 A.M., with Resident #17 revealed the facility did not honor her low salt diet when serving meals. Interview on 04/12/23 at 4:18 P.M., with State Tested Nurse Aide (STNA) #632 revealed Resident #17 preferred to not eat salty foods. STNA #632 stated she was unaware of Resident #17's diet orders but stated Resident #17 would become upset when she was served things like ham sandwiches because the resident stated she was not supposed to have salty foods. Observation on 04/13/23 at 8:10 A.M., with Resident #17's breakfast meal tray revealed the resident was served ham, eggs, toast, and cream of wheat. Interview with STNA #730 at the time of the observation verified Resident #17 was served ham for breakfast. STNA #730 stated she was an agency staff and was unaware of Resident #17's diet order. Review of Resident #17's breakfast meal ticket, dated 04/13/23, revealed the resident was on a regular, no added salt diet. The meal ticket did not indicate no ham, bacon, sausage, or hot dogs. Interview on 04/13/23 at 8:19 A.M., with Dietary Aide (DA) #641 revealed nursing staff were to complete a diet communication form indicating a resident's diet orders and send to the kitchen for the dietary meal ticket to be generated. DA #641 verified Resident #17's meal ticket did not indicate she was not to have ham, bacon, sausage, or hot dogs. DA #641 stated she was unaware Resident #17 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 16 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 not supposed to have those food items since it was not on the meal ticket. Level of Harm - Minimal harm or potential for actual harm Telephone interview on 04/13/23 at 9:25 A.M., with Registered Dietitian (RD) #710 verified Resident #17's diet order was a no added salt, regular diet with thin liquids and no ham, bacon, sausage, or hot dogs. While salt was not added to foods prepared by the kitchen, RD #710 confirmed ham, bacon, sausage and hot dogs were specifically identified due to their high salt content. RD #710 stated nursing staff should be communicating diet orders to the kitchen. Residents Affected - Few Review of the policy titled Diet Orders/Meal Preferences, revised July 2018, revealed nursing would complete a Dietary Communication form and send to dietary in order to generate a tray ticket. Dietary staff would print tray tickets for each meal to reflect the ordered diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 17 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 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 medical record review, staff interview and policy review, the facility failed to administer medications per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/13/21. Diagnoses included cerebral infarct, epilepsy, hypertension, cognitive communication deficit, status post gastrostomy, aphasia, and dysphagia oropharyngeal phase status post cerebral infarct. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was cognitively impaired and required the extensive assistance of one staff for activities of daily living and was dependent on staff for eating, had a gastrostomy tube for feeding and medication administration due to dysphagia. Review of the current orders for Resident #43 revealed orders dated 09/15/22 for the gastrostomy tube patency and placement to be verified with 30 milliliters (ml) of air before each medication administration and feeding and for the gastrostomy tube to be flushed with 30 ml of water before and after medication administration. Orders initiated on 09/16/22, for the diagnosis of hypertension called for amlodipine 10 milligrams (mg) to be administered per gastrostomy tube every morning, hydralazine 50 mg administered per gastrostomy tube three times a day and lisinopril 40 mg administered per gastrostomy tube once a day. Review of the medication administration record for February 2023 revealed lisinopril 40 mg was documented as on hold on 02/21/23 at 5:06 A.M., amlodipine 10 mg was on hold on 02/21/23 at 5:06 A.M. and hydralazine 50 mg was on hold on 02/02/23 at 11:35 A.M., 02/21/23 at 5:06 A.M., 02/22/23 at 12:19 P.M. and on 02/26/23 at 12:05 P.M. and documented as not administered on 02/04/23 at 9:39 A.M. and 02/20/23 at 11:44 A.M. Review of the medication administration record for March 2023 revealed hydralazine 50 mg was on hold on 03/01/23 at 12:45 P.M., 03/12/23 at 5:57 P.M., 03/19/23 at 12:32 P.M. and 5:37 P.M., 03/21/23 at 11:21 A.M., 03/31/23 at 11:27 A.M. and not administered on 03/11/23 at 12:23 P.M., 03/12/23 at 12:21 P.M., 03/23/23 at 12:02 P.M., 03/25/23 at 6:51 P.M. and 03/26/23 at 6:15 P.M. Review of the medication administration record for April 2023 revealed hydralazine 50 mg had not been administered as ordered on 04/11/23 at 11:33 A.M. and 4:16 P.M. Review of the medical record and the medication administration records for February, March and April 2023 remained silent for documentation related to medications being held or not administered and further remained silent for the physician notification related to the medications held or not administered. Interview on 04/12/23 at 3:50 P.M., with the Interim Director of Nursing (DON) verified hydralazine and lisinopril were ordered and there are no parameters in place to hold the medications. Interim DON further verified both the hydralazine and lisinopril were held without physician notification and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 18 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 added the facility policy regarding medication administration was not followed. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Medication Administration, dated May 2019 revealed prescribed medications are ordered and delivered in a timely fashion, if medications are withheld the licensed nurse professional administering the medications shall appropriately mark the electronic medical record and document the reason. The physician shall be notified when the medication is not given, and the physician notification is to be documented in the electronic medical record. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 19 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of Medscape medication prescribing information, and review of policy, the facility failed to ensure two (#36 and #49) residents did not receive antipsychotic medications without an appropriate diagnosis or treatment of a specific condition. In addition, the facility failed to ensure one resident's (#48) as needed (PRN) use of anxiety medications were not utilized beyond 14 days without physician review and failed to update the physician order with an end date once reviewed by the physician. This affected three (#36, #48, and #49) of five residents reviewed for unnecessary medications. The facility census was 55. Findings include: 1. Review of Resident #36's medical record revealed an admission date of 04/21/22. Diagnoses included hypertensive heart disease with heart failure, congestive heart failure (CHF), pulmonary hypertension, atrial fibrillation, chronic obstructive heart disease (COPD), rheumatoid arthritis, primary biliary cirrhosis, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired and required extensive two-person assistance with toilet use, bed mobility, dressing, personal hygiene and set up assistance with eating. In addition, Resident #36 received antipsychotic medication seven days of the look back period, with active diagnoses including CHF, heart failure, Alzheimer's disease, COPD, atrial fibrillation, rheumatoid arthritis, primary biliary cirrhosis, and gastroesophageal reflux disease (GERD). Review of a plan of care focus area initiated 04/26/22 revealed Resident #36 had potential for drug related complications associated with use of psychotropic medications related to antidepressant, anxiety, insomnia, antipsychotic use, and dementia. Interventions included observe, document, and report to the physician as needed signs and symptoms of drug related complications, maintain behavior monitoring program to monitor behaviors twice daily and as needed, monitor for target behaviors, and document per facility protocol, and consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. Review of current physician orders revealed Resident #36 was ordered Seroquel (antipsychotic medication) 50 milligrams (mg) twice daily for dementia without behavioral disturbance. In addition, behavior monitoring each shift. Review of the Medication Administration Record (MAR) from 01/01/23 through 04/12/23 confirmed Resident #36 received Seroquel twice daily as ordered. Additionally, behavior monitoring was completed twice daily with no behaviors documented behaviors during the reviewed period. Review of nursing progress notes from 01/01/23 through 04/12/23 revealed no behaviors were documented for Resident #36. Review of nurse practitioner progress notes dated 01/09/23 and 03/17/23 revealed no specific behavioral concerns and no nursing concerns identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 20 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a physician progress note dated 02/09/23 revealed no specific behavioral concerns and no nursing concerns identified. Observations on 04/10/23 at 1:41 P.M.; 04/11/23 at 2:54 P.M., 4:27 P.M., and 5:25 P.M.; 04/12/23 at 7:10 A.M., 11:18 A.M., 3:55 P.M., and 4:22 P.M.; and on 04/13/23 at 9:41 A.M. revealed Resident #36 in bed with the television on during each of the observations. No behavioral concerns were observed. Interview on 04/12/23 at 3:55 P.M., with Interim Director of Nursing (IDON) #613 verified Resident #36 had no psychiatric diagnosis to support the use of Seroquel, other than dementia. In addition, IDON #613 verified Resident #36 had no behaviors documented from 01/01/23 through 04/12/23 and nurse practitioner notes dated 01/09/23 and 03/17/23 and physician note dated 02/09/23 also revealed no specific behaviors were identified for Resident #36. IDON #613 stated hospice prescribed Seroquel for Resident #36 and there had been an on-going concern related to hospice prescribing too many medications. Interview on 04/12/23 at 4:22 P.M., with State Tested Nurse Aide (STNA) #632 revealed Resident #36's behaviors typically consisted of yelling out and attempting to get out of bed when she was in pain or if her brief was soiled. STNA #632 stated Resident #36 calmed down once her needs were addressed. STNA #632 denied Resident #36 was ever combative. Interview on 04/12/23 at 4:28 P.M., with Licensed Practical Nurse (LPN) #631 revealed Resident #36 could become agitated. LPN #631 stated the agitation typically presented as yelling or trying to get out of bed. LPN #631 stated most of the time, Resident #36's behaviors subsided once her needs were addressed. LPN #631 was unaware of Resident #36 being combative. Review of Medscape Seroquel (quetiapine - generic medication name) prescribing information, located at https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984#0, revealed the medication was prescribed to treat Schizophrenia and Bipolar Disorder in geriatric populations. In addition, off-label (not approved) prescribing for psychosis and agitation in Alzheimer's dementia. Further review revealed a Black Box Warning indicting the medication was not approved for dementia-related psychosis; elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (for example, heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Review of the policy titled Antipsychotic/Psychotropic Medications and GDRs, revised January 2019, revealed if an order for an antipsychotic/psychotropic medication is written by the attending physician/nurse practitioner, he or she have assessed, properly diagnosed, and documented in the medical record the resident requires the use of the antipsychotic/psychotropic medication. 2. Review of Resident #48's medical record revealed an admission date of 02/25/23. Diagnoses included aftercare following explanation of knee joint prosthesis, presence of cardiac pacemaker, obstructive sleep apnea, chronic pulmonary embolism, presence of right artificial knee joint, morbid obesity, irritable bowel syndrome, asthma, chronic kidney disease, fibromyalgia, right heart failure, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toilet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 21 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 use and personal hygiene. Level of Harm - Minimal harm or potential for actual harm Review of a plan of care focus area, initiated 03/09/23, revealed Resident #48 had potential for drug related complications associated with use of psychotropic medication related to antidepressant and antianxiety medication use. Interventions included observing, documenting, and reporting signs and symptoms of drug related complications and consulting with the pharmacy and physician regarding Gradual Dose Reduction (GDR) when clinically appropriate. Residents Affected - Few Review of a physician order, with a start date of 02/24/23, revealed Resident #48 was ordered alprazolam (antianxiety medication) 0.5 milligrams (mg) three times daily as needed for anxiety. The order did not contain a stop date for the medication. Review of the Medication Administrator Record (MAR) from 02/24/23 through 04/12/23 revealed Resident #48 received alprazolam beyond the initial 14 days (03/09/23) on the following dates: 03/11/23, 03/15/23, 03/16/23, 03/17/23, 03/19/23, 03/20/23, 03/22/23, 03/28/23, 03/29/23, 03/31/23, and 04/12/23. Review of a pharmacy recommendation dated 03/27/23 revealed all as needed (PRN) psychoactive medications must initially be limited to 14 days in duration. The prescriber must then reassess the resident to continue the PRN order. The pharmacy requested documentation of rational for continued use and the duration. Further review revealed on 03/31/23, the physician provided rational of Generalized Anxiety Disorder (GAD) and extended the use of the PRN alprazolam for 30 days. Interview on 04/13/23 at 12:49 P.M., with Interim Director of Nursing (IDON) #613 verified the order for PRN alprazolam was continued beyond the initial 14 days without the physician assessing Resident #48 for continued use. In addition, IDON #613 verified the physician order was not updated with a stop date once reviewed by the physician on 03/31/23. Review of the policy titled Antipsychotic/Psychotropic Medications and GDRs, revised January 2019, revealed PRN psychotropic medication orders were limited to 14 days. The physician or nurse practitioner, if appropriate, may extend the PRN order beyond 14 days but should document their rationale in the resident's medical record and indicate the duration of the PRN medication. 3. Review of the medical record for Resident #49 revealed an admission date of 05/17/22, diagnoses included chronic kidney disease, dementia, chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #49 was cognitively impaired and required the extensive assistance of one staff for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and required the limited assistance of one staff for walking and eating. In addition, Resident #49 received antipsychotic medication seven days of the look back period, with active diagnoses including chronic kidney disease, dementia, and chronic obstructive pulmonary disease. Review of a plan of care focus area initiated 12/15/22 revealed Resident #49 had potential for drug related complications associated with use of psychotropic medications. Interventions included observe, document, and report to the physician as needed signs and symptoms of drug related complications, monitor for target behaviors and document per facility protocol, and consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 22 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of current physician orders revealed Resident #49 was ordered Seroquel (antipsychotic medication) 75 milligrams (mg) at bedtime for agitation and restlessness, Seroquel 25 mg once daily at 4:00 P.M. for anxiety and restlessness and an as needed dose of Seroquel 25 mg at bedtime if the bedtime dose of Seroquel was not effective for dementia without behavioral disturbance. In addition, behavior monitoring each shift. Residents Affected - Few Review of the Medication Administration Record (MAR) for January 2023 revealed Seroquel 25 mg had been administered nightly as ordered from 01/01/23 to 01/30/21. On 01/31/23 the bedtime dose of Seroquel was increased to 50 mg and was administered on 01/31/23. Review of the MAR for February 2023 revealed the bedtime dose of Seroquel was increased to 75 mg nightly and on 02/23/23 an additional dose of Seroquel 25 mg was ordered at bedtime if the 75 mg dose was ineffective. Resident #49 received Seroquel as ordered and had not received any as needed doses. Review of the MAR for March 2023 revealed Seroquel 75 mg at bedtime was administered as ordered and the as needed dose of Seroquel 25 mg had not been administered but continued to be reordered every 14 days. Review of the MAR for April 2023 revealed a dose of Seroquel 25 mg once daily at 4:00 P.M. had been added for restlessness. The daily 4:00 P.M. dose and the nighttime dose of Seroquel had been administered as ordered. An additional dose of Seroquel 25 mg was administered on 04/09/23 at bedtime. Review of nursing progress notes from 01/01/23 through 04/12/23 revealed no behaviors were documented for Resident #49. Review of nurse practitioner progress notes dated 01/12/23, 02/10/23 and 03/09/23 revealed no specific behavioral concerns and no nursing concerns identified. Observations on 04/10/23 at 3:12 P.M.; 04/11/23 at 3:20 P.M., 04/12/23 at 8:00 A.M., 12:06 P.M., and on 04/13/23 at 8:55 A.M. revealed Resident #49 was interacting with others and visiting with family at bedside during the observations. No behavioral concerns were observed. Interview on 04/12/23 at 4:00 P.M., with Interim Director of Nursing (IDON) #613 verified Resident #49 had no psychiatric diagnosis to support the use of Seroquel, other than dementia. In addition, IDON #613 verified Resident #49 had no behaviors documented from 01/01/23 through 04/12/23 and nurse practitioner notes dated 01/12/23, 02/10/23 and 03/09/23 revealed no specific behaviors were identified for Resident #49. IDON #613 stated hospice prescribed Seroquel for Resident #49 and there had been an on-going concern related to hospice prescribing too many medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 23 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of policy, the facility failed to ensure insulin was administered as ordered. This affected one resident (#53) of ten residents observed during medication administration. The facility census was 55. Residents Affected - Few Findings include: Review of Resident #53's record revealed an admission date of 11/23/21. Diagnoses included acute respiratory failure with hypoxia, type II diabetes mellitus, border bipolar, hypertension, persistent vegetative state, and tracheostomy due to an anoxic brain injury. Review of a physician order dated 09/06/22 revealed Resident #53 was ordered Humalog Insulin, 100 units per milliliter to be administered per sliding scale before meals and at bedtime. The sliding scale stated for a blood sugar between 0-69 milligrams per deciliter (mg/dl) to hold insulin and initiate hypoglycemia protocol, for a blood sugar between 70-139 mg/dl, hold insulin, a blood sugar between 140-160 mg/dl required the administration of 3 units of insulin, a blood sugar between 161-190 mg/dl required the administration of 4 units of insulin, a blood sugar between 191-230 mg/dl required the administration of 5 units of insulin, a blood sugar between 231- 270 mg/dl required 6 units of insulin to be administered and a blood sugar between 271-999 mg/dl required the administration of 7 units of insulin and for the physician called if the blood sugar was greater than 400 mg/dl. Observation of Registered Nurse (RN) #602 on 04/12/23 at 11:06 A.M., revealed RN #602 completed hand hygiene and completed a blood sugar check for Resident #53 with a blood sugar result of 210 mg/dl. Continued observation of RN #602 revealed the nurse returned to the medication cart outside the door of Resident #53, completed hand hygiene, opened the top drawer of the medication cart and removed the individually labeled insulin pen for Resident #53, RN #602 then removed two alcohol pads and needle, also from the top drawer, then removed the cap from the insulin pen, opened one of the alcohol prep packages, removed the alcohol pad and cleansed the top of the insulin pen, attached the needle to the insulin pen, and dialed the insulin pen to 5 units. RN #602 picked up the second alcohol pad package and entered the room of Resident #53 holding the insulin pen in the right hand. Observation continued, RN #602 opened the alcohol package and used the alcohol swab to cleanse the lateral upper right arm of Resident #53 followed by the administration of the subcutaneous injection of 5 units of Humalog insulin into the lateral right upper arm of the resident. Interview on 04/12/23 at 11:10 A.M., with RN #602 stated insulin pens are only required to be primed with 2 units of insulin when first opened and no priming of the insulin pens are required with each individual dose of insulin. RN #602 verified the insulin pen for Resident #53 had not been primed prior to the administration of the 5 units of insulin. Interview on 04/12/23 at 4:00 P.M., with the Interim Director of Nursing (DON) verified insulin pens are required to be primed with 2 units of insulin after the needle is attached for each insulin administration. Review of the undated policy titled Administering Medications Insulin Administration, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 24 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 06/17/21, stated insulin pen requiring priming prior to administration and manufacturer's recommendations should be check prior to use. Review of insulin Humalog manufacturer's instructions, revised April 2020, revealed priming with 2 units of insulin is required prior to use of the insulin pen to ensure air is removed from the needle and the cartridge that may collect during normal use and to prime priming ensures the pen is working correctly. If you do not prime before each injection, too much or too little insulin may be administered. Event ID: Facility ID: 366192 If continuation sheet Page 25 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 - Few 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** Based on medical record review, observation, staff interview, review of manufacturer's drug facts labels, and review of policy, the facility failed to ensure medications were securely stored. This affected one (#20) of one resident reviewed for medication storage. The facility identified one (#42) cognitively impaired and independently mobile residing on the B Hall. The facility census was 55. Findings include: Review of Resident #20's medical record revealed an admission date of 05/16/22. Diagnoses included Alzheimer's disease, osteoarthritis, atherosclerotic heart disease, essential hypertension, major depressive disorder, and dementia with psychotic disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Review of current physician orders revealed no orders for zinc oxide or muscle rub cream. Review of an undated Self-Administration of Medications Assessment revealed Resident #20 was deemed unable to safely self-administer medications. Observation on 04/10/23 at 1:44 P.M., revealed Resident #20 lying in bed. On a bedside table, located to the left inside the door to the room, was a box containing an opened one-ounce tube of zinc oxide and an unopened box containing a one and one-quarter ounce tube of muscle rub cream. Interview on 04/10/23 at 2:16 P.M., with Licensed Practical Nurse (LPN) #659 verified the zinc oxide and muscle rub cream in Resident #20's room and said they should not have been left unsecured. LPN #659 stated someone likely left the zinc oxide in the room after applying it to Resident #20. LPN #659 stated the muscle rub cream was not from the facility and was probably brought in by someone. LPN #659 verified neither the zinc oxide nor muscle rub cream were ordered for the resident and said she would lock them in the treatment cart. Review of the undated manufacturer's drug facts label for the zinc oxide revealed warnings which included avoid contact with eyes and keep out of reach. Review of the undated manufacturer's drug facts label for the muscle rub revealed warnings which included for external use only, avoid contact with eyes and mucus membranes, and keep out of reach. Review of the policy titled Storage of Medications, revised May 2019, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 26 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interview, review of sanitizer log and policy review, the facility failed to ensure foods were stored in a safe and sanitary manner. In addition, the facility failed to ensure the chemical dish washing machine had the proper chemical sanitizer level for effective disinfection of dishes and utensils. This had the potential to affect 52 residents who receive food from the kitchen. Three residents (#37, #43 and #53) received no food by mouth and thus no food from the kitchen. The facility census was 55. Findings include: Observation on 04/10/23 at 8:43 A.M., of main kitchen's walk-in cooler found a ten inch by twelve inches by six-inch-deep steam table tray full of meatballs in a red sauce on a wheeled cart in line for use. The date marked was 03/30/23, eleven days prior. Interview on 04/10/23 at 8:46 A.M., with Dietary Staff (DS) #662 verified the date on the meatballs was the use by date and they should have been thrown away and not in line for use. Observation on 04/10/23 at 8:50 A.M., of the dry storage area found a one-gallon jug of soy sauce open and partially used on the dry storage shelf. The label on the soy sauce read Refrigerate After Opening. Interview on 04/10/23 at 8:51 A.M., with DS #655 verified the gallon jug of soy sauce was open, approximately 1/4 of it was used and it was stored in the dry storage area and was not refrigerated as it should have been. DS #655 said it would be thrown out. Observation on 04/10/23 at 8:55 A.M., of the dishwashing machine found it was a low temperature chemical machine. Observations of the chemicals connected to the machine found two dishwashing detergents and a rinse solution. No sanitizer was found. Observation on 04/10/23 at 9:02 A.M., of DS #655 completing a chemical test strip found the sanitizer level was zero. Coinciding interview with DS #655 verified the white five-gallon jug contained dish soap, the one-gallon pink jug contained dish soap, the blue one-gallon jug contained a rinsing agent and there was no sanitizer connected to the dishwasher. DS #655 reported he was not sure how long there was no sanitizer connected to the machine but there should have been. Interview on 04/10/23 at 9:06 A.M., with Dietary Manager (DM) #606 verified there was a mix up with the chemicals and there should have been a dish soap and a sanitizer not two dish soaps connected to the machine. DM #606 stated they would have the dishwashing machine repair person come out today and correct the machine. While they waited, they would wash in the three-sink system and provide disposable items. Observation on 04/11/23 at 7:28 A.M., of the dishwasher in the main kitchen found a yellow one-gallon jug of sanitizer, a pink one-gallon jug of dish soap, and a blue one gallon of jug of rinse agent connected to the dishwashing machine. Coinciding interview with DS #655 verified the machine maintenance company came out yesterday and corrected the issue. DS #655 verified the issue was the white five-gallon bucket was dish soap and was supposed to be yellow sanitizer. They had been running two dish soaps and no sanitizer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 27 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Facility's Dish Machine Chlorine Sanitizer Log revealed in March 2023 only one A.M. chlorine level was taken, and the last P.M. level taken was on 03/24/23. There were no sanitizer level tests logged from 03/25/23 to 04/10/23. Review of the policy titled, Food Storage revised March 2022 revealed left over food was to be used within seven days or discarded. Event ID: Facility ID: 366192 If continuation sheet Page 28 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 - Potential for minimal harm Residents Affected - Many 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 medical record review, staff interview, and review of facility policy, the facility failed to ensure resident's vaccination records and screenings were documented in the resident's personal medical record. This affected four (#20, #37, #38, and #42) of five residents reviewed for immunizations, with the potential to affect all 55 residents. The facility census was 55. Findings include: 1. Review of Resident #20's medical record revealed an admission date of 05/16/22. Diagnoses included Alzheimer's disease, osteoarthritis, atherosclerotic heart disease, essential hypertension, major depressive disorder, and dementia with psychotic disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was severely cognitively impaired. Review of immunizations documented in the Electronic Medical Record (EMR) revealed Resident #20 received a COVID-19 immunization on 11/29/22. No additional information related to the COVID-19 vaccination was in the EMR, including additional immunization dosages, manufacturer, or lot number. Further review of the EMR revealed no information related to influenza or pneumococcal vaccinations or Tuberculosis (TB) screening upon admission. 2. Review of Resident #37's medical record revealed an admission date of 05/06/19. Diagnoses included Parkinson's disease, unspecified sequelae of cerebral infarction, solitary pulmonary nodule, morbid obesity, major depressive disorder, dysphagia, aphasia, nontraumatic intracranial hemorrhage, hypertension, and type II diabetes. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 was severely cognitively impaired. Review of immunizations documented in the EMR revealed Resident #37 received a COVID-19 immunization on 11/29/22. No additional information related to COVID-19 vaccination was included in the EMR, including any additional immunization dosages, manufacturer, or lot number. Further review of the EMR revealed no information of influenza or pneumococcal vaccinations or initial TB screening. 3. Review of Resident #38's medical record revealed an admission date of 07/05/22. Diagnoses included dementia, osteoarthritis, cardiomegaly, essential hypertension, heart failure, hypertensive heart disease, mild cognitive impairment, history of falling, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired. Review of immunizations documented in the EMR revealed Resident #38 received a COVID-19 immunization on 07/28/22. No additional information related to COVID-19 vaccinations was included in the EMR, including any additional immunization dosages, manufacturer, or lot number. Further review of the EMR revealed no information related to influenza or pneumococcal vaccinations or initial TB screening. 4. Review of Resident #42's medical record revealed an admission date of 09/10/21. Diagnoses included osteoarthritis, hypertension, history of falling, major depressive disorder, dementia, and osteoporosis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 was severely cognitively impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 29 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 - Potential for minimal harm Residents Affected - Many Review of immunizations documented in the EMR revealed Resident #42 received a COVID-19 immunization on 11/29/22. No additional information related to the COVID-19 vaccination was included in the EMR, including any additional immunization dosages, manufacturer, or lot number. Further review of the EMR revealed no information related to influenza or pneumococcal vaccinations or initial TB screening. Interview on 04/11/23 at 1:54 P.M., with the Administrator revealed the facility documented TB screenings and vaccination status on a spreadsheet. While vaccination declinations were scanned into the EMR, the Administrator stated administered vaccinations were not documented in the EMR and the facility did not utilize paper charts. Follow up interview on 04/12/23 at 12:08 P.M., with the Administrator again verified immunizations were not documented in Residents #20, #37, #38 and #42's medical records. The Administrator provided spreadsheet information to verify immunizations and TB screenings were provided. Review of the policy titled Vaccination Policy, dated July 2021, revealed if a resident received a vaccine, the following information would be included in the medical record: site of administration, date of administration, lot number of the vaccine, expiration date of the vaccine, manufacturer of the vaccine, and name of the person administering the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 30 of 31 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 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 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 Based on observation, staff interview, and review of policy, the facility failed to ensure hand hygiene was performed after providing resident care during meal tray service. This affected two (#3 and #315) of 52 residents observed during meal service. The facility census was 55. Residents Affected - Few Findings include: Observation on 04/10/23 at 11:55 A.M. revealed lunch meal trays being passed on the C Hall. State Tested Nurse Aide (STNA) #725 was observed at the tray cart, wearing gloves. STNA #725 removed a meal tray from inside of the cart, placed it on top of the cart, poured a cup of juice and a cup of coffee, placed the cups on the meal tray, and entered Resident #3's room. Continued observation revealed STNA #725, using gloved hands, physically assist Resident #3 with repositioning in bed and, using the same gloved hands, touched the bed controls to raise Resident #3's head. STNA #725 removed the plate cover from the resident's meal and pushed the over the bed table over Resident #3. STNA #725 exited Resident #3's room without removing the gloves or performing any type of hand hygiene and returned to the meal cart and removed another lunch meal tray. STNA #725 placed the meal tray on top of the cart, poured a cup of juice and a cup of coffee, placed the cups on the meal tray, and entered Resident #315's room. Continued observation revealed STNA #725 speaking with Resident #315. STNA #725 was leaning against the wall, using her left, gloved hand, to hold herself against the wall. STNA #725 continued speaking with Resident #315, approached his meal tray, removed the plate cover for his meal, and moved the over the bed table over the resident. STNA #725 exited Resident #315's room and removed the gloves. Interview on 04/10/23 at 12:06 P.M., with STNA #725 revealed she typically wore gloves when delivering meal trays on the halls. STNA #725 stated before beginning tray services, she washed her hands, then donned gloves, but did not typically change her gloves in between resident rooms or meal trays. STNA #725 verified she physically assisted Resident #3 with repositioning in bed and adjusted the Resident's bed while wearing gloves and did not change her gloves or perform any type of hand hygiene prior to pouring drinks for Resident #315's meal and delivering his lunch tray to his room. In addition, STNA #725 verified she wore the same gloves during meal service and did not remove them or perform any hand hygiene until she exited Resident #315's room. STNA #725 asked if she should wash her hands between resident rooms. Review of the policy titled Handwashing, revised November 2021, revealed handwashing must be appropriately completed after handling items potentially contaminated with blood, body fluids, excretions, or secretions and the use of gloves does not replace hand washing. This deficiency represents non-compliance investigated under Complaint Number OH00141941. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366192 If continuation sheet Page 31 of 31