Health inspection·November 23, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 11/22/22 at 8:23 A.M. revealed Resident #14 sleeping with her breakfast tray in front of her. Continued observation at that time revealed State Tested Nurse's Aide (STNA) #209 entered Resident #14's room and offered to assist with her breakfast meal. Interview on 11/22/22 at 9:09 A.M. with STNA #209 revealed she fed Resident #14 her breakfast. STNA #209 further revealed Resident #14 was often tired the morning after dialysis. Interview on 11/22/22 at 9:38 A.M. with Registered Nurse (RN) #216 revealed staff had not reported any changes in condition to her about Resident #14. Observation on 11/22/22 at 11:56 A.M. revealed STNA #217 removing Resident #14's noon meal tray from her room. Interview at that time revealed STNA #217 fed Resident #14 her lunch, and stated it was unusual for Resident #14 to require assistance with eating. Interview on 11/22/22 at 3:43 P.M. with RN #216 revealed she was unable to safely administer Resident #14's afternoon medications because Resident #14 could not stay awake long enough to swallow them. Further interview revealed no staff reported a change in condition to RN #216 regarding Resident #14. Continued interview revealed Resident #14 was able to feed herself the previous week. Review of progress notes dated 11/22/22 at 3:44 P.M. and 4:11 P.M. revealed Resident #14 did not receive three afternoon medications as they were unable to be given safely. Interview on 11/23/22 at 8:15 A.M. with RN #216 revealed she did not report Resident #14's inability to take her medications on 11/22/22 but waited until the morning of 11/23/22 to notify the Nurse Practitioner when she was in the facility. 2. Review of the medical record for Resident #6 revealed an admission date of 11/16/18 with medical diagnoses of hemiplegia affecting left nondominant side, nontraumatic intracerebral hemorrhage, and contracture of the left hand. Review of the quarterly MDS dated [DATE] revealed Resident #6 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for eating, and total dependence of two people for transfers. Review of a progress note dated 11/04/22 revealed Resident #6 had a reddened area on her coccyx with top layer of skin sloughing off. Further review revealed the resident's representative was not notified of the change in condition. Review of a progress note dated 11/09/22 revealed Resident #6's reddened area on her coccyx opened. Further review revealed the resident's representative was not notified. Review of a skin assessment dated [DATE] revealed Resident #6 had a stage two pressure (partial thickness loss of dermis) ulcer to her coccyx. Interview on 11/23/22 at 8:10 A.M. with the Regional Nurse Consultant #240 confirmed the record revealed no indication Resident #6's representative was notified when the reddened area on her coccyx appeared on 11/04/22, or when it worsened to a stage two on 11/09/22. Review of the undated facility policy titled Notification of Changes revealed the facility would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 2 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 consult with the resident's physician and notify the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status, and when there is a need to alter treatment or commence a new form of treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 3 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to investigate an injury of unknown origin. This affected one resident (#6) of twelve records reviewed. The facility census was 22. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 11/16/18 with medical diagnoses of hemiplegia affecting left nondominant side, nontraumatic intracerebral hemorrhage, and contracture of the left hand. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, and toileting, extensive assistance of one person for eating, and total dependence of two people for transfers. Review of a progress note dated 11/09/22 revealed Resident #6 had a bruise and abrasion to right lower leg. Review of the active physician orders for Resident #6 revealed no treatment orders for resident's left lower leg. Review of the facility's self-reported incidents (SRIs) revealed no incident reported for Resident #6's bruise and abrasion noted on 11/09/22. Interview on 11/23/22 at 8:10 A.M. with the Regional Nurse Consultant #240 revealed the facility could not determine the origin of Resident #6's bruise and abrasion to her left lower leg. Further interview confirmed the facility did not investigate the origin of the bruise and abrasion. Review of undated facility policy titled Abuse revealed the facility would investigate all injuries of unknown sources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 4 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record of Resident #126 revealed an admission date of 11/19/22. Diagnoses include benign prostatic hypertrophy, atrial fibrillation, heart failure, and hypertension. The MDS assessment had not been completed. Review of the medical record for Resident #126 revealed the baseline care plan had not been completed as of 11/23/22. Interview on 11/23/22 at 10:00 A.M. with LPN #204 provided verification no baseline care plan had not been completed to date. Review of the undated facility policy titled Baseline Care Plan revealed the facility would develop a baseline care plan within 48 hours of a resident's admission. Based on staff interview, record review, and review of the facility policy, the facility failed to accurately complete baseline care plans. This affected two residents (#14, and #175) of the four residents review for baseline care plans. Facility also failed to complete baseline care plans for residents. This affected one resident (#126) of four records reviewed for baseline care plans. The facility census was 22. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 10/19/22 and a readmission date of 11/21/22 with medical diagnoses of a fracture of her left ankle, type two diabetes mellitus, congestive heart failure (CHF), acute and subacute hepatic failure, hyperkalemia, acute kidney failure, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, and toileting, extensive assistance of one person for hygiene, and supervision with setup help only for eating. Review of the baseline care plan for Resident #14 revealed it was undated. Review of the comprehensive care plan for Resident #14 revealed it was initiated 10/24/22. Interview on 11/22/22 at 10:12 A.M. with Licensed Practical Nurse (LPN) #204 confirmed Resident #14's baseline care plan was undated and therefore could not verify if it was completed within 48 hours of admission. 2. Review of the medical record for Resident #175 revealed an admission date of 11/07/22, with medical diagnoses of pulmonary hypertension, anemia, hypoosmolality and hyponatremia, hypothyroidism, chronic atrial fibrillation, anorexia, and irritable bowel syndrome. Review of the MDS assessment dated [DATE], revealed Resident #175 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, walking, and toileting, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 5 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0655 required extensive assistance of one person for dressing and hygiene. Level of Harm - Minimal harm or potential for actual harm Review of the baseline care plan for Resident #175 revealed it was undated. Review of the comprehensive care plan for Resident #175 revealed it was initiated 11/11/22. Residents Affected - Few Interview on 11/22/22 at 4:10 P.M. with the Social Services Director #205 confirmed Resident #175's baseline care plan was undated and therefore could not verify if it was completed within 48 hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 6 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure finger nail care was provided to a resident that was dependent on staff for personal hygiene. This affected one resident (#5) of two residents reviewed for activities of daily living (ADLs). The census was 22. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 08/10/20. Diagnoses included other specified intracranial injury, duodenal ulcer, gastrostomy status, adjustment disorder with depressed mood, post traumatic seizures, and hyperlipidemia. Review of the most recently completed Minimum Data Set (MDS) assessment completed 10/02/22, revealed Resident #5 had severely impaired cognitive skills for daily decision making and required total dependence with two-plus persons physical assistance with personal hygiene, and was assessed with no rejection of care. Review of an ADLs deficit care plan dated 10/27/20, revealed Resident #5 needed hands on assistance with most ADLs tasks due to having uncoordinated muscle movements. Observation on 11/22/22 at 9:12 A.M., revealed Resident #5 sitting in his wheelchair in his room with his arms and hands folded over his lap. Observation of Resident #5's right hand revealed the thumb nail was nearly one-half inch long and was partially torn from left to right. Resident #5's left hand had finger nail length between one-fourth and one-half inch on the thumb, fourth, and fifth fingers. Interview on 11/22/22 at 9:15 A.M., with Registered Nurse (RN) #216 stated sometimes Resident #5's family complained to her about Resident #5's finger nails being too long and then the staff would cut them. RN #216 stated usually the night shift staff get Resident #5 up for the day and perform his personal hygiene. Observation of Resident #5's long finger nails on 11/22/22 at 9:15 A.M., during interview with RN #216 verified Resident #5's finger nails needed trimmed and stated it appeared some of Resident #216's finger nails were not trimmed for a long time. Review of an undated ADLs policy revealed a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 7 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 observations, interviews with staff and resident's representative, and medical record review, the facility failed to ensure physician orders were followed to treat edema. This affected one resident (#4) of the one resident reviewed with edema. Facility also failed to initiate interventions for treatment of a fistula (an abnormal connection between two body parts). This affected one resident (#13) of the four residents reviewed with wounds. The census was 22. Residents Affected - Few Findings include: 1. Review of Resident #4's medical record revealed an admission date of 04/08/22. Diagnoses included congestive heart failure, mild cognitive impairment, anxiety, metabolic syndrome, major depression, unspecified psychosis, and unspecified dementia with mild mood disturbance. Review of the most recent Minimum Data Set (MDS) assessment completed 10/19/22 revealed Resident #4 was assessed with severely impaired cognitive skills for daily decision making, was not assessed to reject care, and required extensive one-person physical assistance with dressing and personal hygiene. Review of a physician order dated 04/08/22 revealed Resident #4 was ordered compression stockings to bilateral legs to be applied in the morning and off at night for edema. Interview on 11/21/22 at 12:40 P.M. with Resident #4's representative, they stated Resident #4 was supposed to have on compression stockings during the day and the facility was not putting them on consistently. Resident #4's representative stated resident was in the facility on 11/19/22 and Resident #4 did not have on compression stockings. Observation 11/21/22 at 3:50 P.M., on 11/22/22 at 8:01 A.M., at 9:59 A.M., at 11:07 A.M., and at 2:07 P.M. revealed Resident #4 was not wearing compression stockings. Interview on 11/22/22 at 2:09 P.M. with Registered Nurse (RN) #216 stated no one reported to her that Resident #4 refused any care on 11/22/22. Observation on 11/22/22 at 2:15 P.M. with RN #216 revealed Resident #4 standing in her bedroom at the bedside. RN #216 had Resident #4 sit down in her reclining chair and lifted both of her pant legs revealing no compression stockings on Resident #4's legs. Resident #4's bilateral ankles were noted to be slightly swollen with no indentation or weeping noted. Interview on 11/22/22 at 2:19 P.M. with RN #216 stated Resident #4 was usually dressed in the mornings before she got to work, and no one told her she did not have the compression stockings on. Interview on 11/23/22 at 11:17 A.M. with Regional Nurse Consultant (RNC) #240 stated the facility did not have a policy for treatment of edema. 2. Review of the medical record of Resident #13 revealed an admission date of 09/02/20. Diagnoses include chronic peripheral venous insufficiency, low back pain, essential hypertension, osteoarthritis, and major depressive disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 8 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 Review of the quarterly MDS assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 required extensive assistance of two staff for bed mobility, dressing and personal hygiene and was totally dependent on staff for transfers. Review of the care plan initiated 09/18/20 for Resident #13 revealed a potential for pressure ulcer development related to disease process and immobility. Interventions include to apply a cream every shift and turn and reposition every two hours. Review of the general surgeon consult note dated 11/22/22 for Resident #13 revealed resident was diagnosed with a fistula, was ordered Augmentin (antibiotic) 875 milligrams (mg) twice daily for 14 days and a sitz bath (a warm water bath you sit in to relieve discomfort in the perineal region) to be given twice daily. Review of the physician orders for Resident #13 revealed an order for the Augmentin but orders were silent for sitz baths being ordered. Interview on 11/23/22 at 8:40 A.M. with State Tested Nursing Assistant #209 revealed she had been told about the sitz bath but not how to complete them. STNA #209 added the facility did not have a bathtub so they could not do sitz baths. Interview on 11/23/22 at 8:45 A.M. with Registered Nurse (RN) #216 verified the general surgeon had ordered for Resident #13 to receive sitz baths and verified the sitz baths had not been ordered. RN #216 stated the facility did not have bathtub and therefore could not do sitz baths. RN #216 stated Resident #13 was unable to sit due to poor trunk control. RN #213 indicated she was going to discuss with the Certified Nurse Practitioner (CNP), on how to best accomplish sitz baths. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 9 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, staff interview, and medical record review, the facility failed to ensure a gastrostomy tube stoma (insertion site of gastrostomy tube) dressing was in place as ordered. This affected one resident (#5) of one resident reviewed with g-tubes tubes. Resident #5 was the only resident in the facility with a gastrostomy tube. The census was 22. Findings include: Review of Resident #5's medical record revealed an admission date of 08/10/20. Diagnoses included other specified intracranial injury, duodenal ulcer, gastrostomy status, adjustment disorder with depressed mood, post traumatic seizures, and hyperlipidemia. Review of the most recently completed Minimum Data Set (MDS) assessment completed 10/02/22 revealed Resident #5 had severely impaired cognitive skills for daily decision making, was assessed with a feeding tube, and was assessed with no rejection of care. Review of a nutritional risk care plan dated 08/17/20 revealed an intervention to provide Resident #5's feeding tube site care per physician orders. Review of a physician order dated 10/07/22 revealed Resident #5 was to have his feeding tube site cleansed with soap and water, rinsed, patted dry, and a dressing applied two times daily. Observation on 11/22/22 at 9:04 A.M. revealed Registered Nurse (RN) #216 removed Resident #5's abdominal binder to administer his scheduled supplemental nutrition through his feeding tube. Further observation revealed no dressing was in place at the feeding tube site. Resident #5's feeding tube site was free from redness and drainage. Interview on 11/22/22 at 9:05 A.M. with RN #216 stated Resident #5 was supposed to have a dressing around the feeding tube insertion site and verified it was not in place. RN #216 stated no one told her Resident #5 did not have a dressing on feeding tube site. Interview on 11/23/22 at 11:17 A.M. with Regional Nurse Consultant (RNC) #240 stated the facility did not have a policy related to treatments for feeding tubes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 10 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing tool and staff interview, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours daily. This affected all 22 residents residing in the facility. Residents Affected - Many Findings include: Review of the staffing tool from 11/06/22 to 11/12/22 revealed on 11/11/22 (Friday) the facility had an RN on duty for only one hour and on 11/12/22 (Saturday) the facility had an RN on duty for only six hours and 15 minutes. Interview on 11/23/22 at 11:55 A.M. with Administrator provided verification of the lack of RN coverage on the two days. Administrator additionally indicated the DON worked 16 hours on 11/10/22 (Thursday) and DON did not work any hours on 11/11/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 11 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 and staff interview the facility failed to have accurate diagnoses for psychotropic medications. This affected two residents (#14, and #124) of five reviewed for unnecessary medications. The facility census was 22. Findings include: 1. Review of the medical record of Resident #124 revealed an admission date of 11/17/22. Diagnoses include acute respiratory failure, atrial fibrillation, hypertension chronic kidney disease osteoarthritis, type II diabetes mellitus, polyneuropathy, hyperlipidemia, major depressive disorder, and gastroesophageal reflux disease. The record was silent for any diagnosis for anxiety. Review of the physician orders for Resident #124 revealed an order for Buspar (an anti-anxiety) five milligrams (mgs) twice daily for depression. An order for Hydralazine (vasodilator) 10 mg three times daily for anxiety. Interview on 11/23/22 at 10:20 A.M. with Regional Director of Nursing (R-DON) #240 provided verification of the incorrect diagnoses for the Buspar and Hydralazine. 2. Review of the medical record for Resident #14 revealed an admission date of 10/19/22 and a readmission date of 11/21/22 with medical diagnoses of a fracture of her left ankle, type two diabetes mellitus, congestive heart failure, acute and subacute hepatic failure, hyperkalemia, acute kidney failure, and anxiety disorder. Review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #14 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, and toileting, extensive assistance of one person for hygiene, and supervision with setup help only for eating. Review of a physician order dated 11/15/22 revealed Resident #14 was prescribed Mirtazapine (anti-depressant) tablet 7.5 milligrams, one tablet by mouth at bedtime for anxiety. Interview on 11/23/22 at 9:47 A.M. with the Regional Nurse Consultant #240 confirmed the treatment diagnosis of anxiety was an inappropriate indication for Mirtazapine for Resident #14. Review of the product label for Mirtazapine, available at (https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020415s023s024.pdf), accessed 11/25/22, revealed it was indicated for the treatment of major depressive disorder. Review of the facility policy titled Psychotropic Medications revealed all orders for psychoactive medications will include an appropriate diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 12 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 interviews, and review of the facility policies, the facility failed to store and prepare food in a sanitary manner, failed to completely cover hair during meal service, and failed to accurately monitor sanitizer levels in the sanitation buckets used to clean the kitchen. This had the potential to affect all residents in the facility except one (#5) who was identified as receiving no food by mouth. The facility census was 22. Findings include: 1. Observations during the initial tour of the kitchen on 11/21/22 at 8:07 A.M. revealed unsealed ham, unsealed hotdogs, an undated opened package of ham, and pizza sauce dated 11/02/22 in the walk-in refrigerator. Further observation revealed omelets open to the air in the freezer. Concurrent interview with the Dietary Manager #237 confirmed the observations. Further interview revealed food should be labeled with a date and sealed. Observation on 11/22/22 at 10:20 A.M. of the refrigerator designated for residents' food revealed a package of pepperoni with a fuzzy appearance on it consistent with mold, an unlabeled, thawed commercially prepared meal with instructions to keep frozen, an undated quart-size container of thickened cranberry juice, approximately ¼ full, and an undated, unlabeled frozen meal encrusted with ice. Concurrent interview with STNA #209 confirmed the findings. Observation of meal service on 11/22/22 beginning at 10:52 A.M. revealed the [NAME] #212 wearing plastic gloves on both hands while preparing meal trays. Further observation revealed she opened the oven, opened the refrigerator, used the sink, used the food processor, and used serving utensils to serve the meal. Continued observation revealed she prepared a grilled cheese sandwich and placed her gloved hand on the left side of the sandwich to hold it in place while she used the spatula to cut the sandwich. Interview at that time with the [NAME] #212 stated the last time she changed her gloves was before the surveyor entered the kitchen at 10:52 A.M. Continued observation at that time revealed the [NAME] #212 continued to prepare meal trays. Subsequently, the [NAME] #212 began to prepare a deli turkey sandwich and asked the surveyor if she should change her gloves again. 2. Observation during meal service on 11/22/22 beginning at 10:52 A.M. revealed the cook wearing a hairnet with her bangs exposed. Further observation at that time revealed the Director of Environmental Services #223 walking in the immediate vicinity of food service wearing a hairnet with his ponytail coming out from underneath. Concurrent interview on 11/22/22 at approximately 11:15 A.M. with the Dietary Manager #237 confirmed both staff were wearing hairnets in a way that did not cover all of their hair while standing near food being plated for residents. 3. Observation on 11/22/22 at 1:22 P.M. of the Dietary Manager #237 testing the sanitation level in the sanitizer buckets revealed she used pH (a quantitative measure of the acidity or basicity of aqueous or other liquid solutions) strips rather than testing for parts per million (PPM) which tests the solute load of solution. Concurrent interview with the Regional Dietary Manager (RDM) #241 confirmed the strips were pH strips. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 13 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 Interview on 11/22/22 at 2:59 P.M. with the RDM #241 confirmed the facility used the wrong test strips for the sanitation buckets. Further interview revealed she spoke with the chemical company who would send PPM strips the following day. Review of the undated facility policy titled Food Storage Cold revealed refrigerated items will be labeled and dated. Review of the undated facility policy titled Food Safety and Sanitation Review revealed open foods are sealed, labeled, and dated in storage areas, all foods are covered, labeled, and dated, proper hand washing practices are followed, gloves are used when handling ready to serve items, and employees are to have hair restrained appropriately during their shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 14 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER), the facility failed to have an effective quality assurance program to address repeated concerns identified during three consecutive annual surveys. This affected all residents in the facility. The facility census was 22. Findings include: Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) report dated 10/28/22 revealed the facility received a deficiency for failing to be free from unnecessary psychotropic medications during the annual surveys completed in October 2018 and November 2019. Review of the medical records during the annual survey conducted 11/21/22 through 11/23/22 for three residents (#14, #124, and #126) revealed the facility failed to have appropriate diagnoses in place for psychotropic medications. Interviews on 11/23/22 at 9:47 A.M. and 10:20 A.M. with Regional Nurse Consultant #240 confirmed the diagnoses for psychotropic medications for Resident #14, Resident #124, and Resident #126 were in appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 15 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 observations, staff interview and review of online resources from the Centers for Disease Control (CDC) guidelines, the facility failed to ensure appropriate infection control techniques were performed during wound care. This affected one resident (#124) of the three residents reviewed for wounds. Facility census was 22. Residents Affected - Few Findings included: Review of the medical record of Resident #124 revealed an admission date of 11/17/22. Diagnoses include acute respiratory failure, atrial fibrillation, hypertension chronic kidney disease osteoarthritis, type II diabetes mellitus, polyneuropathy, hyperlipidemia, major depressive disorder, and gastroesophageal reflux disease. The minimum data set assessment had not been completed. Review of the baseline care plan, undated, revealed resident had a coccyx pressure injury with a goal to heal the injury. Interventions included resident to have a specialty mattress and perform wound care as ordered. Review of the admission assessment for Resident #124 revealed resident had an open area to the coccyx measuring one centimeter (cm) by one cm without any description as to color, depth, odor, or drainage. Review of the physician orders for Resident #124 revealed an order dated 11/17/22 for collagenase ointment (used to remove damaged tissue from chronic skin ulcers) 250 units per gram to be applied to resident's coccyx wound daily for wound healing and cover wound with Mepilex. Observation on 11/22/22 at 3:20 P.M. revealed Registered Nurse (RN) #216 prepared supplies to complete wound care for Resident #124. RN #216 washed her hands, applied gloves, and asked Resident #124 to stand from her recliner. RN #216 pulled Resident #124's pants down to her knees and removed the contaminated Mepilex dressing from the resident's coccyx wound. RN #216 opened a three-milliliter (mL) vial of normal saline, moistened a four by four (4x4) gauze, and cleaned resident's coccyx wound with normal saline. Continued observation revealed RN #216 applied a small amount of collagenase ointment to her contaminated gloved finger and spread it on and around the resident's coccyx wound. RN #216 opened a new Mepilex dressing and applied it over the coccyx wound. RN #216 assisted Resident #124 to pull her pants back up and sit down in recliner. RN #216 removed gloves and washed her hands. Interview on 11/22/22 at 3:40 P.M. with RN #216 verified the above wound care techniques. RN #216 verified she did not change gloves and perform hand hygiene when she removed the contaminated dressing and before she applied collagenase ointment with her contaminated gloves and applied the new dressing. Review of CDC website titled Hand Hygiene Guidance (https://www.cdc.gov/handhygiene/providers/guideline.html) dated 01/30/20, revealed the core infection prevention and control practices for safe care delivery in all healthcare settings recommends healthcare personnel should use an alcohol based hand rub or wash with soap and water before moving from soiled body site to a clean body site on the same patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 16 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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, staff interview, and review of a facility policy, the facility failed to ensure resident's received influenza vaccinations upon request and failed to offer pneumococcal vaccinations per the facility policy. This affected two residents (#14 and #127) of five residents reviewed for vaccinations. The census was 22. Residents Affected - Few Findings include: Review of Resident #127's medical record revealed an admission date of 11/08/22. Diagnoses included unstable angina, heart failure, chronic kidney disease, essential hypertension, and generalized anxiety. Review of influenza documentation in the medical record revealed Resident #127 last received the influenza vaccine on 09/29/21. Review of a document titled, Influenza Flu Vaccine Risk/Benefits and Consent, dated December 2016, revealed Resident #127 indicated she would like the influenza vaccine to be administered and signed the document on 11/09/22. An unidentified Licensed Practical Nurse (LPN) signed the document as a witness with a date of 11/09/22. Review of physician orders, medication administration records, and treatment administration records from November 2022 revealed no documentation Resident #127 received an order to administer the vaccine or any documentation the vaccine was administered. Interview on 11/23/22 at 9:38 A.M. with Regional Nurse Consultant (RNC) #240 verified Resident #127 signed an influenza consent form on 11/09/22 indicating she wanted the influenza vaccination and there was no documentation Resident #127 received the influenza. RNC #240 stated the influenza vaccine was available in the facility on 10/03/22 and could be administered right away. 2. Review of Resident #14's medical record revealed an original admission date of 10/19/22 and a most recent admission date of 11/21/22. Diagnoses included chronic kidney disease, diabetes mellitus type II, congestive heart failure, anxiety, and hyperkalemia. Review of Resident #14's face sheet dated 11/21/22 revealed a date of birth [DATE] ([AGE] years old). Review of Resident #14's immunization history revealed no documentation of a pneumococcal vaccination. Review of Resident #14's medical record revealed no documentation of Resident #14 being offered the pneumococcal vaccination upon admission or receiving the vaccination during her stay in the facility. Interview on 11/23/22 at 10:01 A.M. RNC #240 verified residents should be offered pneumococcal vaccinations on admission and verified there was no documentation Resident #14 previously received the pneumococcal vaccine or was offered the vaccination in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366224 If continuation sheet Page 17 of 18 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 366224 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens at Celina 1301 Myers Road Celina, OH 45822 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of a facility policy titled, Influenza and Pneumococcal Vaccine Policy, revised 07/25/07, revealed all newly admitted residents will be assessed for pneumococcal vaccine status upon admission. Residents without proof of previous pneumococcal vaccination should receive one dose of pneumonia vaccine per CDC (Centers for Disease Control and Prevention) guidelines if consent and physician orders are obtained. Educational material will be provided to resident/representative so that informed decision can be made. Influenza immunization must be offered annually beginning in the fall if vaccine is available. Event ID: Facility ID: 366224 If continuation sheet Page 18 of 18