Inspection·December 18, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many through in-person and phone communication, all facility staff on the abuse policy. All staff included: five Registered Nurses (RN), 14 Licensed Practical Nurses (LPN), 26 State Tested Nursing Assistants (STNA), four Hospitality Aides, two Maintenance Staff, seven Dietary Aides, one Activity Director, one Activity Aid, six Housekeepers and five Administration employees. This education included the requirement to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. • Beginning on 11/28/23 and concluding on 11/28/23 the DON and the Assistant Director of Nursing (ADON) completed education with all staff on communicating if there are any supply, vendor and/or food supply concerns to immediately notify the DON and the Administrator. All staff included five Registered Nurses (RN), 14 Licensed Practical Nurses (LPN), 26 State Tested Nursing Assistants (STNA), four Hospitality Aides, two Maintenance Staff, seven Dietary Aides, one Activity Director, one Activity Aid, six Housekeepers and five Administration employees. • On 11/28/23 the DON and ADON completed a review of all 43 resident records to verify there was no change of condition related to the facility's lack of payment to vendors. • Beginning on 11/28/23, the Administrator and/or designee monitors and ensures essential resident care services are provided by daily (Business Days) communication in stand-up meeting with facility leadership team by asking if there are any essential vendor concerns. • Beginning on 11/28/23, the Administrator and/or designee will communicate facility needs to the management company (Chief Compliance Officer #602, Chief Executive Officer #601, and/or Chief Financial Officer #600) as they arise via email communication. • On 11/28/2023 at 1:00 P.M. an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the QAPI Plan to address potential for resident abuse /neglect as it pertains to financial solvency due to issues that arose in the facility. In-person attendance included the Administrator, Assistant Administrator, Director of Nursing, Business Office Manager (BOM) #100, and Dietary Director #105. Medical Director #110, Chief Compliance Officer (CCO) #602 and Chief Financial Officer (CFO) #600 attended via phone. • BOM #100 and Receptionist #200 were re-educated on 11/28/2023 by the Administrator on the Stampli process. BOM #100 and/or designee and Receptionist #200 scan bills into Stampli (online portal for the Management Company's (located in Florida) approval and payment). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 2 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 • Level of Harm - Immediate jeopardy to resident health or safety On 11/28/23, Corporate Compliance Officer #602 re-educated the Administrator, Assistant Administrator and DON on the abuse policy. This education included the requirement to meet financial obligations for the delivery of care and maintenance and to operate in a manner to ensure all bills were being paid timely to prevent potential interruption in services and to meet the total care needs of all the residents admitted to and/or retained in the facility. Residents Affected - Many • Beginning 11/28/23, Social Services #120 and/or designee will interview four residents weekly for four weeks and then randomly thereafter to ensure their needs are being met. • Beginning 11/28/23, the DON or Designee would interview five clinical employees weekly for four weeks and randomly thereafter to verify that staff have adequate supplies, food and staffing to meet the needs of the residents. • Beginning 11/29/23, the Administrator and/or designee and CFO #600 and/or designee would complete weekly audits for four weeks and then randomly thereafter of financial obligations to essential resident care services (food, pharmacy, oxygen, medical supplies, therapy, staff) by ensuring that invoices were being paid and that no disconnect/cut off/end of service notifications were delivered within the week. • Beginning 11/29/23, weekly conference calls would be held on Wednesdays with the Administrator and/or designee with the management company (Corporate Compliance Officer, CEO, or CFO) to communicate any concerns with essential resident care services weekly for 12 weeks. • Beginning 11/29/23, the Administrator and/or designee would verify with the Management Company (CEO, CFO, and/or Corporate Compliance Officer) that the following vendors bills were made current or placed on a payment plan: a. AEP (Electric) - On 12/11/23 account payments were made in the amounts of $103.82, and $7,876.51 (checks were delivered via FedEx on 12/13/23). b. [NAME] (Trash) - On 11/27/23 payment in the amount of $488.75 was posted to the account. c. Respiratory Care Partners (Oxygen) - On 12/06/23 a delinquent balance of $396.25 was paid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 3 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 d. City of Barnesville Water - On 12/12/23 delinquent payment was made in the amount of $2,498.27. Level of Harm - Immediate jeopardy to resident health or safety e. [NAME] County Treasurer (Property Taxes) Parcel 1 - Payment Plan initiated on 11/16/23 with 12 Residents Affected - Many $6,613.50. Payments concluding on 10/16/24. Initial payment made on 11/16/23 monthly payments of via cashier's check in the amount of $13,612.00 (November and December payment for both parcels). f. [NAME] County Treasurer (Property Taxes) Parcel 2 - Payment Plan initiated on 11/16/23 with 12 monthly payments of $192.45. Payments concluding on 10/16/24. Initial payment made on 11/16/23 via cashier's check in the amount of $13,612.00 (November and December payment for both parcels). g. Medline (Medical Supplies) - A payment plan was initiated company wide to include a minimum payment of $15,000 each week via electronic payment. A payment of $7,135.78 was made on 11/20/23 and a payment of $3,340.01 was made on 12/11/23. h. Broad River (Therapy) - A payment plan was initiated on 12/14/23 with an electronic payment of $5,457.23 made. The facility indicated a payment plan contract was implemented to pay the oldest invoices first, starting with the September 2023 invoice (paid on 12/14/23). A conference call would be held on 12/14/23 to discuss the next payments. i. AT&T - A payment of $1,738.93 was made on 12/13/23 via phone debit transaction. j. Ohio Hills Health Services (OHHS) for the Medical Director's services - A payment plan was initiated on 12/07/23 to include paying three invoices in December 2023 and two invoices per month for the first six months in 2024 to bring the account current (the outstanding balance amount was not provided to the surveyor from the account manager at OHHS). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 4 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 • Level of Harm - Immediate jeopardy to resident health or safety Results of all audits and interventions were reviewed during an Ad Hoc QAPI meeting on 12/12/23 at 9:30 A.M. Attendees included the Administrator, Assistant Administrator, DON, [NAME] Date Set (MDS) Registered Nurse (RN) #8, Social Service Director (SSD) #64, Business Office Manager (BOM) #116, Therapy Director #230, Infection Preventionist (IP) Licensed Practical Nurse (LPN) #112, and Unit Manage LPN #120. The Medical Director was notified via phone. The results of all audits and interventions will be brought to the facility's monthly QAPI meeting for three months and as needed for review and recommendations. Residents Affected - Many Although the Immediate Jeopardy was removed on 12/14/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure compliance. Findings Include: On 12/05/23 at 1:10 P.M. an interview with the Administrator revealed he was the Administrator at this facility as well as a sister facility, Astoria Place of Cambridge. The Administrator stated he was unaware of the extent of the financial issues this facility was experiencing until the complaint survey was in-progress at Astoria Place of Cambridge. The Administrator shared corrective actions from Astoria Place of Cambridge were also implemented at this facility, beginning on 11/28/23. On 12/06/23 at 2:35 P.M. an interview with Business Office Manager (BOM) #46 revealed most facility bills were sent directly from vendors to Epic Healthcare Solutions (the facility management company located in Florida). All bills and invoices received at the facility were scanned and emailed directly to Stampli (company that processes and pays invoices) every Wednesday. There was no evidence these bills were monitored to ensure they were being paid in a timely manner or to ensure payments were made as required to prevent outstanding balances or termination notices for the facility. Payroll information was sent to the corporation on a Monday and paper checks were sent overnight to the facility for payday (every other Friday). On 12/07/23 at 2:40 P.M. an interview with the Administrator regarding the facility finances and billing/payment process revealed BOM #46 would forward invoices and bills received at the facility to Stampli via email. The Administrator revealed the facility did not pay any of the vendors directly for services rendered at the facility, the payments were being made by an accounts payable department based in Florida. There was no evidence the facility had a comprehensive and effective system in place to monitor the financial solvency of the facility, to ensure bills were being paid timely, vendors were paid the amount due and/or the facility was meeting all financial obligations. The following financial solvency concerns were identified (to include but not limited to) the following as a result of the complaint investigation: a. On 12/05/23 at 2:25 P.M. an interview with the Administrator revealed there were 14 employees who did not receive paychecks on 10/13/23 as their checks were returned due to insufficient funds. The Administrator did not provide any additional information as to why payroll was not met for these employees on this date. On 12/05/23 at 1:25 P.M. an interview with Housekeeping Staff #74 revealed they had a paycheck from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 5 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 10/13/23 returned due to insufficient funds. Level of Harm - Immediate jeopardy to resident health or safety On 12/05/23 at 1:30 P.M. an interview with Laundry Staff #6 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. Residents Affected - Many On 12/05/23 at 1:35 P.M. an interview with Licensed Practical Nurse (LPN) #128 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 9:51 A.M. an interview with Housekeeping Staff #80 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 10:01 A.M. an interview with Activity Staff #56 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 10:08 A.M. an interview with Dietary Staff #96 revealed they had a paycheck from 10/13/23 returned due to insufficient funds. On 12/07/23 at 2:40 P.M. interview with the Administrator revealed BOM #46 sent payroll information to corporate on a Monday and paper checks were sent overnight to the facility for payday (every other Friday). The Administrator stated paper checks had been used for several months but he was unsure why this was changed from direct deposit. Further interview revealed the Administrator called corporate on 10/13/23 when his check was returned for insufficient funds and again on 10/16/23 when the checks for 13 additional employees were returned on 10/16/23 due to insufficient funds. The Administrator identified himself, the Director of Nursing (DON), the Assistant Administrator, Licensed Practical Nurse (LPN) #210, Activity Director #56, Marketing Director #14, Dietary Director #98, Dietary Staff #88, #90 and #96, Housekeeping Staff #12, #74 and #218, and Maintenance Director #54 who had payroll checks returned due to insufficient funds. The 14 staff (the Administrator, DON, the Assistant Administrator, LPN #210, Activity Director #56, Marketing Director #14, Dietary Director #98, Dietary Staff #88, #90, #96, Housekeeping Staff #12, #74, #218 and Maintenance Director #54) identified were verified with facility payroll records to have payroll checks dispersed and dated 10/13/23. Review of the undated facility Employee Handbook revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposit. During orientation, the human resources representative would assist with signing up for either direct deposit or a Pay Card. b. The following vendor/suppliers were reviewed as part of the State agency investigation with financial solvency concerns including but not limited to the following: 1. Review of the statement issued by [NAME] Innovative Management Partners, dated 11/18/23, revealed the facility owed a balance of $133,353.10 with invoices dated back to June 2023. The facility owed the amount of $77,020.88 that was over 90 days past due. This vendor was the facility's previous food supply vendor. On 12/05/23 at 1:50 P.M. an interview with Dietary Director (DD) #98 revealed food service vendors were changed from [NAME] Distributors on 10/28/23 to [NAME] Food Services starting 10/29/23. DD #98 stated the previous food budget was set at $1,700.00 per week, which was a low dollar amount and made it difficult to order needed food items due to the increased food costs. DD #98 revealed she would have to borrow items from her emergency food supply to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 6 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 get through to the next week and then replace items with the next order. Level of Harm - Immediate jeopardy to resident health or safety On 12/11/23 at 11:30 A.M. an interview with the Administrator revealed the facility's outstanding balance to [NAME] Distributors was $133,353.10 which included labor, food services, and supplies. Residents Affected - Many 2. Review of a bill from Barnesville Water Department, dated 11/21/23, revealed the facility account was delinquent with an amount due of $2,498.27. The bill included, if payment was not received by 12/05/23, service would be terminated without further notice. Review of check #1006, from Bank of Oklahoma, dated 12/01/23 revealed payment of $2,498.27 made to the order of Barnesville Water Department. On 12/11/23 at 9:34 A.M. an interview with Barnesville Water Department Clerk #330 revealed a check payment was received on 12/05/23 for $2,298.27 and the payment was deposited on 12/05/23. However, on 12/08/23 there was a notice the payment had been returned due to an incorrect routing number on the check. Barnesville Water department Clerk #330 confirmed the recent bill dated 11/21/23 was a delinquent notice with possible termination of services if the amount was not paid by 12/05/23. Further interview with the clerk revealed concerns the facility/Epic Healthcare Solutions was always late on their payments for water services. On 12/15/23 at 11:01 A.M. an additional interview with Barnesville Water Department Clerk #330 revealed the delinquent statements are sent out to accounts which have a history of late payments. Epic Healthcare Solutions has a history of having late payments with the water department and would only send payment once the delinquent notice was received for the amount due including a 10% late fee. She also verified it is their practice to issue the shut off notice if payment is not received, and the facility was addressed in the same manner as a residence. 3. Review of an invoice from American Electric Power (AEP) Ohio, dated 11/29/23, revealed the facility had an amount due of $7,876.57, with a disconnection date of 12/08/23, if payment was not received. Review of check #1007 from Bank of Oklahoma, dated 12/01/23, revealed a payment of $7,876.51 paid to the order of AEP Ohio. On 12/12/23 at 10:20 A.M. an interview with AEP Customer Service Representative #365 revealed a check payment was received on 12/06/23 for $7,876.57. However, on 12/11/23 the payment for $7,876.57 was returned with no reason noted. An additional interview on 12/13/23 at 10:35 A.M. with AEP Customer Service Representative #377 revealed the facility had a current outstanding account balance of $10,891.71 due 12/29/23. A past due balance of $7,876.57 was due immediately. Per the representative, there were no pending payments noted to be on the account as of this date (12/13/23). 4. Review of an invoice from American Telephone and Telegraph (AT&T) dated 11/19/23 revealed a current charge of $640.27 with a past due balance of $2,182.82 resulting in total amount of $2,823.09 due in full by 12/19/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 7 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of an email communication from Director of Finance #608 to the Administrator, dated 12/08/23, revealed a forwarded email, dated 12/07/23 at 5:01 P.M., from AT&T Business Payment Confirmation, showing a payment confirmation via bank debit for AT&T account. The payment amount and date of payment was not made available. On 12/13/23 at 10:43 A.M. an interview with AT&T Collections Representative #370 revealed a payment of $2,823.09 was received on 12/04/23. On 12/08/23 the same payment was returned due to an incorrect routing number. On 12/04/23 there was a credit placed on the account for $427.65 making the current amount owed $1,738.93 due immediately with the account being in jeopardy of termination. On 12/13/23 at 10:55 A.M. the Administrator and CFO #600 paid the account balance of $1,783.93 via the facility's petty cash credit card with the amount loaded onto the card by CFO #600. 5. Review of an invoice from the [NAME] County Treasurer Office dated 10/14/23 revealed two parcels of property located at the facility's address. The first parcel property tax amount of $79,362.61 with a payment noted on 11/17/23 for $13,227.10 bringing the current balance owed to $66,135.51. The second parcel property tax amount of $2,309.34 with a payment noted on 11/17/23 for $384.90 bringing the current balance owed to $1,924.44. On 12/11/23 at 9:52 A.M. an interview with [NAME] County Treasurer Clerk #373 revealed there was a payment plan contract dated 11/16/23 for monthly payments of $6,613.55 for the first parcel and $192.45 for the second parcel with each payment due on the 16th of each month. [NAME] County Treasurer Clerk #373 verified there were two separate payments on 11/16/23, one for $6,613.55 and the other for $384.90. 6. On 12/07/23 at 2:40 P.M. interview with the Administrator revealed the previous contracted therapy company (Arbor Therapy) terminated services on 09/17/23 (due to payment issues) and a new therapy company (Broad River Therapy) began services on 09/18/23. On 12/11/23 at 9:46 A.M. an interview with a Representative from Broad River Therapy #376 revealed the facility began services on 09/18/23 and the first invoice #106861 was sent on 10/03/23 for $5,457.23 with payment due on 11/02/23. On 11/02/23 a second invoice was sent for $18,688.17 due on 12/02/23. The facility had a current outstanding balance of $18,688.17 due immediately. Broad River Therapy #376 revealed the facility entered a payment plan contract, on 12/14/23 to pay the oldest invoices for the facility starting on 12/14/23 for the September invoice payment of $5,457.23 with a conference call to schedule the next set of payments (the conference call was also scheduled for 12/14/23). On 12/14/23 at 10:39 A.M. an interview with Arbor Rehabilitation and Healthcare Inc. Chief Executive Officer (CEO) #503 revealed therapy services provided by his therapy company in the facility, were ended due to lack of payment. The facility owes $187,594.25 for therapy services accrued from 01/17/22 to 09/17/23. CEO #503 stated the facility would not commit to a payment plan because it was too binding, and they wanted flexibility. CEO #503 stated monthly payments were not being made and a payment had not been made since 03/30/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 8 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Review of an Excel Spreadsheet, created by Arbor Rehabilitation and Healthcare Inc. dated 11/15/23 and provided by CEO #503, verified the facility owed $187,594.23. 7. Review of the invoice for Medline Medical Supplies revealed an outstanding balance for Epic Healthcare Solutions of $41,659.20. The facility provided a payment plan that was corporation wide and not specific to the facility. The weekly agreed upon payments were to be between $15,000.00 to $20,000.00 entity wide. There were payments made on 11/20/23 for $7,135.78 and on 12/11/23 for $3,340.01 which were specifically for the facility. (However, the information regarding how the payments were made was not provided during the survey). Attempts were made to contact Medline regarding payments and outstanding balances. Medline did not return calls or emails. 8. On 12/11/23 at 11:45 A.M. an interview with [NAME] Credit Account Manager #245 revealed the facility had been 90 days delinquent with their invoice payments resulting in a suspension of service for the last week of October (10/29/23 - 11/04/23). The delinquent payment plus late fees totaled $1,552.00 and was paid on 11/06/23 and the facility service was restored. 9. On 12/11/23 at 10:35 A.M. an interview with Ohio Hills Health Services Office Manager #380 revealed Medical Director services had not been paid by the facility since 04/2023. Medical director service charges were $2,000.00 per month. A payment plan, dated and signed 12/14/23, revealed an electronic payment was to be paid by the 15th of each month in the amount of $6,000.00 until the account was paid current. The first payment was to be paid by electronic payment on 12/14/23 for $6,000.00. The current outstanding account balance was $16,000.00. On 12/11/23 at 2:00 P.M. during an interview with the Medical Director (MD) #225, the MD revealed he was aware the facility was not paying for his services as medical director. MD #225 revealed he had also been made aware by the Administrator related to the concerns with payroll not being met on 10/13/23. However, the MD denied knowledge of other unpaid vendors including water and electricity. On 12/12/23 at 10:33 A.M. an interview with Chief Financial Officer (CFO) #600 revealed the facility had attempted to make payments for some outstanding invoices/bills on 12/01/23; however, most were returned. CFO #600 revealed he believed the reason for the most recent vendor payments being returned was due to a new program offered through Bank of Oklahoma which required a routing number to be assigned prior to checks being sent out as payment. When the facility corporation, Epic sent out checks at the beginning of December 2023, the new program had not been implemented completely with the routing numbers which caused the checks to be returned. CFO #600 gave no explanation for the lack of payments to facility vendors resulting in high outstanding balances and shut-off notices to the water and electric and disconnect notices for the facility phone lines that was noted to be occurring prior to 12/01/23. Review of the undated Nursing Facility admission Agreement, provided upon admission to the facility, revealed the facility would provide routine nursing care and supplies, meals, housekeeping, social services, activities, laundry, and medical supplies. Review of the Facility Assessment, dated 09/12/23, revealed the facility's residents were at a clinically complex and special high categories who oftentimes have one or more chronic or comorbid conditions including their acuity. Residents of the facility were at risk for falls, pressure ulcers, infections, incontinence, increased disability, weight loss, depression, and other potential areas of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 9 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0600 decline. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy titled, Abuse Prevention, Identification, Investigation and Reporting Policy revised 08/15/22 revealed, Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00148884. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 10 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interview, the facility failed to establish an effective governing board, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care and maintenance. This had the potential to affect all 42 residents in the facility. Findings include: Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator and to the compliance and ethics officer by scheduling executive board sessions with the compliance and ethics officer that allows for a free flow of information without potential for conflict. Review of the administrator job description revealed he worked with the office manager to disburse money, record transactions, and obtain receipts for any monetary transactions. The job description indicated the administrator was ultimately responsible for petty cash and all accounts receivable; and establishing contracts with consultants and reviewing and evaluating the consultant reports and recommendations. Review of the facility assessment dated [DATE] revealed the facility provided all care and services as required in the requirements of participation including, but not limited to assistance with activities of daily living, personal care services, medication administration, pain management, infection prevention and control, nutritional services, skin care, fall and injury prevention, pharmacy, and therapy services. Additionally, the facility provided medical director, attending physicians, physician assistants, nurse practitioners, dentist, podiatrist, ophthalmologist, and psychiatrist services, and pharmacist. The governing body consisted of Chief Financial Officer #600, Chief Executive Officer #601, and Chief Nursing Officer/Compliance Officer #602. Interview on 12/12/23 at 10:33 A.M. Chief Financial Officer (CFO) #600 revealed most of the facility bills were handled at the corporate office so the facility staff could focus on residents. CFO #600 stated the corporate office was located in Florida. CFO #600 indicated there was close contact with vendors via email or telephone. When asked if there had been any disconnection notices in the last six months, CFO #600 stated no services had been disconnected but they would have to check to see if there were any disconnection notices. When asked about a disconnect notice from Barnesville Water Department, American Electric Power (AEP) and American Telephone and Telegraph (AT&T), and three checks being returned due to incorrect routing number, CFO #600 stated the reason for the most recent vendor payments had been returned was due to the new program offered through Bank of Oklahoma which required a routing number to be assigned prior to checks being sent out as payment. When Epic sent out the checks at the beginning of December the new program had not been implemented completely with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 11 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the routing numbers which caused the checks to be returned. CFO #600 stated an agreement with the [NAME] County Treasurer on 11/16/23 and payments for two months had been made. CFO #600 stated payments and communication were being completed with the previous food vendors and previous therapy company. When asked why bills were behind and payments were not made on time, CFO #600 stated there was communication with vendors to make sure payments were received and essential supplies were provided to the facility. Between 12/05/23 and 12/14/23 additional information was requested from the facility to include a more detailed description of current balances, outstanding balances, dates last payments were made and information from the actual vendor/supplier/utility to review. The following information was provided: a. Review of bill from Barnesville Water Department dated 11/21/23 revealed $2,498.27 was owed and this was a delinquent notice. If payment was not received by 12/05/23, service would be terminated without further notice. On 12/11/23 at 9:34 A.M. an interview with Barnesville Water Department clerk #330 revealed a check payment was received on 12/05/23 for $2,298.27 and the payment was deposited on 12/05/23. On 12/08/23 there was a notice the payment had been returned due to incorrect routing number on the check. b. Review of invoice from American Electric Power (AEP) Ohio dated 11/29/23 revealed $7,876.51 was owed with a disconnection date of 12/08/23 if payment was not received. On 12/12/23 at 10:20 A.M. an interview with AEP Customer Service Representative #365 revealed a check payment was received on 12/06/23 for $7,876.57. On 12/11/23 the payment for $7,876.57 was returned with no reason noted. A further interview on 12/13/23 at 10:35 A.M. with AEP Customer Service Representative #367 revealed the current account balance of $10,891.71 due 12/29/23. The pass due balance of $7,876.57 is due immediately. No pending payments were noted to be on the account. c. Review of invoice from American Telephone and Telegraph (AT&T) dated 11/19/23 revealed a current charge of $640.27 with a past due balance of $2,182.82 resulting in total amount of $2,823.09 due in full by 12/19/23. Review of an email communication from CFO #600 to the Administrator dated 12/08/23 revealed a payment confirmation via bank debit for AT&T account. The payment amount and date of payment was not made available. On 12/13/23 at 10:43 A.M. an interview with AT&T Collections Representative #370 revealed a payment of $2,823.09 was received on 12/04/23. On 12/08/23 the same payment was returned for incorrect routing numbers. d. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 12 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0837 Level of Harm - Minimal harm or potential for actual harm Review of invoice from [NAME] County Treasurer dated 10/14/23 revealed two parcels of property located at the facility's address. The first parcel property tax amount of $79,362.61 with two payments noted on 11/17/23 for $13,227.10 showing the current balance owed of $66,135.51. The second parcel property tax amount of $2,309.34 with two payments noted 11/17/23 for $384.90 showing the current balance owed of $1,924.44. Residents Affected - Many On 12/11/23 at 9:52 A.M. an interview with [NAME] County Treasurer clerk #373 revealed there is a payment plan contract dated 11/16/23 for monthly payments of $6,613.55 for the first parcel and $192.45 for the second parcel. [NAME] County Treasurer clerk #373 verified there were two separate payments on 11/16/23 for $6,613.55 and for $384.90. e. On 12/11/23 at 9:46 A.M. an interview with a representative of Broad River Therapy #376 revealed the facility began services on 09/18/23 and the first invoice #106861 was sent on 10/03/23 for $5,457.23 with payment due on 11/02/23. On 11/02/23 a second invoice was sent for $18,688.17 due on 12/02/23. The current outstanding balance of $18,688.17 is due immediately. f. On 12/14/23 at 10:39 A.M. an interview with Arbor Rehabilitation and Healthcare Inc. Chief Executive Officer (CEO) #503 revealed therapy services were ended due to lack of payment. The facility owes $187,594.25 for therapy services accrued from 01/17/22 to 09/17/23. CEO #503 stated the facility would not commit to a payment plan because it was too binding, and they wanted flexibility. CEO #503 stated monthly payments were not being made and a payment had not been made since 03/30/23. g. On 12/11/23 at 10:35 A.M. an interview with Ohio Hills Health Services office manager #380 revealed the medical director services have not been paid for since 04/2023. Medical director service charges are $2,000.00 per month. There is a payment plan contract with no payments having been made for the services charged. h. Review of the invoice for Medline Medical Supplies revealed an outstanding balance for Epic Healthcare Solutions of $41,659.20. There is a payment plan in place that is entity wide and not specifically for the facility. i. The facility provided a list of 14 employees that had paychecks dated 10/13/23 returned due to insufficient funds. Interview on 12/07/23 at 2:40 P.M. with the Administrator revealed the Administrator identified himself, the Director of Nursing (DON), the Assistant Administrator, Licensed Practical Nurse (LPN) #210, Activity Director #56, Marketing Director #14, Dietary Director #98, Dietary staff #88, #90 and #96, Housekeeping staff #12, #74 and #218, and Maintenance Director #54 that had payroll checks returned due to insufficient funds. Corporate had wired money to employees in the amount of their pay and any fees that had occurred when they were notified a check was returned for insufficient funds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 13 of 14 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 366261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Barnesville 400 Carrie Avenue Barnesville, OH 43713 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 0837 j. Level of Harm - Minimal harm or potential for actual harm On 12/07/23 at 2:40 P.M. an interview with the Administrator revealed [NAME] Distributers were owed $133,353.10 for services accrued from 01/25/23 to 10/28/23. Residents Affected - Many This deficiency represents non-compliance investigated under Complaint Number OH00148884. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 14 of 14