Inspection·March 11, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many this complaint survey, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance Performance Improvement Program provided continual monitoring, which included ongoing compliance with all financial obligations for the delivery of care regarding payroll, therapy services and electricity. On 03/04/24 at 9:10 A.M. an interview with State Tested Nursing Assistant (STNA) # 227 revealed on 02/16/24 her payroll check did not clear the bank. She stated she did not receive her money until 02/26/24 because her bank placed a hold on her pay check. She stated this was not the first time her paycheck had not cleared the bank and she was charged penalties and late fees. On 03/04/24 at 9:15 A.M. an interview with STNA #100 revealed her paycheck on 02/16/24 did not clear the bank. She stated she was assessed fees and she did not get paid until 02/29/24 (13 days after her paycheck was issued). On 03/04/24 at 9:20 A.M. an interview with Laundry #110 revealed she had been employed at the facility for two years. She stated she has had her paycheck returned for insufficient funds four times since October 2023 with the most recent being 02/16/24 but she was waiting to see if her check from 03/01/24 cleared the bank. She stated her bank had placed a 10-day hold on the 03/01/24 pay check. On 03/04/24 at 9:40 A.M. an interview with Dietary Manager #122 revealed her check from 02/16/24 had not cleared the bank. She stated she had not received her payment until the following Wednesday (02/21/24). She stated she had not been reimbursed for wire fees and overdraft fees. She stated she was told it would be on this check but she did not believe it should be on a check with taxes taken out because she was losing money. She believed it should be cash. On 03/04/24 at 9:45 A.M. an interview with [NAME] #124 revealed her payroll check bounced the last two pay periods and she has not been paid the fees associated with the check bouncing. She stated she did not know about this week's check (for payroll on 03/01/24) as of this time. On 03/04/24 at 9:50 A.M. an interview with the Director of Nursing revealed employee payroll checks were not clearing the bank. She stated her paycheck did not clear the last two paydays. She stated she was not leaving (employment) but stated she was only staying because the previous Administrator had quit and she would not do that to the residents. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys in December 2023 and January 2024. He stated on 02/16/24 there was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those were paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) #601, Director of Finances (DOF) #603 and CFO #600 revealed they handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Oakhill Manor. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. He stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 2 of 13 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 03/11/2024 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 their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank that this was a banking error. In addition to the staff payroll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 on this date. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 10:40 A.M. an interview with the Administrator revealed she had just started in the position of Administrator two weeks ago but she was previously the assistant administrator. She stated the corporate office had not given her a reason as to why the staff pay checks were returned for insufficient funds. She stated she does not know if any of the suppliers were being paid, however no suppliers had reached out to her directly in the last two weeks stating they had not been paid. Staff were to come to her about their paychecks and she was letting the corporate office know their checks did not clear the bank. She stated she was told their money would be wired within 24 hours. On 03/04/24 at 2:45 P.M. an interview with Business Office Manager (BOM) #120 revealed most of the bills were paid through the corporate office. She stated the secretary received the statements then she would give them to her, she would go through them, sort them out, and she would give the ones that needed to be paid to the Administrator and she wound send them to the corporate office to be paid. She stated Physician #130 and #131 had come to her asking about payment and she had to reached out the corporate office; however, they said they would take care of it but it never got done. She stated she also was responsible for completing employee payroll. She stated on 02/16/24 the facility had 43 staff members ( STNA #100, #103, #105, #106, #107, #116, #210, #211, #212, #215, #216, #220, #224, #225, #227, #229, #231, #232, #235, #236, LPN #109, #213, #214, #223, #226, #237, Dietary #122, #123, #124, #222, #228, #230, #233, #234, BOM #120, Social Service #217, Housekeeping #118, #119, #126, Marketing #121, Hospitality Aide #219, Maintenance #113 and #218) whose checked did not clear the bank. She stated they had all since been paid but there was a delay in payment. She stated the staff were told to bring her the documentation for the fees they received and they would also be paid. An email from the Administrator dated 03/07/24 at 3:08 P.M. revealed the facility had 23 staff (STNA #101, #102, #212, #224 #242, LPN #125, #223, #237, #240, Dietary #123, #228 , #233, Housekeeping #118, #126, #243, Maintenance #113, #121, Activity #112, #241, Administrator #500, #501, Receptionist #117 and Social Service #217) whose checks where returned for insufficient funds from the 03/01/24 payday. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: a. On 03/04/24 at 10:50 A.M. an interview with Pest Control Service #133 revealed the facility was behind from October 2023 through the present day in the amount of $810.00. She stated since the new company had taken over, they had not paid any invoices for service at all. b. Review of the invoices from Anova Psychiatric Services and Physician #130 revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 3 of 13 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 03/11/2024 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 was billed $500.00 on each month for 04/25/23, 05/25/23, 06/24/23, 07/25/23, 09/25/23 and 10/25/23 for a total of $3000.00. The Administrator did not have the most current invoices. On 03/04/24 at 10:54 A.M. an interview with Physician #130 (Anova Psychiatric Services) revealed he has not been paid for almost a year. He stated he received a paper check in November 2023; however, it was returned for insufficient funds. He stated he had called the corporate office in Florida but just gets the run-a-around. He stated although he had no plans to discontinue service as of this date, he hoped the company resolved the issue soon. Review of the check written on 03/04/24 revealed the facility sent a check to Physician #130 for $3000.00 to pay invoices from 04/25/23 through 10/25/23. c. On 03/04/24 at 11:05 A.M. an interview with Sanitation #213 revealed the facility was 30 days past due with their account. d. On 03/04/24 at 11:50 A.M. an interview with City Water Company Office Manager #134 from Barnesville water revealed the facility had a past due amount of $3345.82 with a current bill of $6420.97 which included the past due and current bill. e. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023; however, CFO #600 reported the facility would be sending out checks this week. Review of the email from Broad River Therapy Services dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $103,531.89. They had a statement from 11/02/23 with a due date of 12/02/23 which was 94 days past due for $27,252.19, a statement for 12/01/23 with a due date of 12/31/23 which was 65 days past due for $28291.58, a statement for 01/02/24 with a due dated of 02/01/24 which was 33 days past due for $22,527.73 and a statement for 02/02/24 with a due date of 03/03/24 which was two days past due for $25,461.39. f. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24. Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services. g. Review of the invoices from the Medical Director (Physician #131) revealed the facility was billed $2000.00 on 12/11/23, 01/10/24, 02/01/24 and 02/28/24 for a total of $8000.00 owed. On 03/04/24 at 2:04 P.M. an interview with Medical Director Office Manager #132 revealed the facility was charged $2000.00 a month for Medical Director services and had not paid in four months. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 4 of 13 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 03/11/2024 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 stated they have an outstanding bill of $8000.00 as of 03/04/24. Level of Harm - Immediate jeopardy to resident health or safety Review of the Nursing Facility admission Agreement, provided to all residents, revealed the facility was responsible for basic services including room and board, routine nursing care and supplies for residents and such other personal services as may be necessary for the resident's health, well-being, and grooming. The facility would also provide meals, linens, housekeeping, social services and activities and other regular services required by law. Residents Affected - Many Review of the Employee Handbook effective 2020 revealed employees would receive their pay reimbursement for hours worked either through Pay Card or Direct Deposition. During orientation, the human resources representative will assist with signing up for either direct deposit or a Pay Card. Review of the facility policy titled, Abuse Prevention, Identification and Reporting, revised 08/15/22, revealed the facility defined resident abuse to include neglect which was the failure of the facility, its employees or service providers, to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress. 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. This deficiency represents non-compliance investigated under Complaint Number OH00151616. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 5 of 13 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 03/11/2024 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, facility assessment review, and interviews, the facility failed to establish an effective governing body, 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. This had the potential to affect all 41 residents in the facility. Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview on 12/05/23 at 2:25 P.M. 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. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances, non-payment and shut off notices being issued to the facility. Following the 12/18/23 survey, the facility provided evidence of payments being made to various different supplies/vendors removing the likelihood of situations of neglect and the resolution of shut off notices for the facility. However, at the time of this complaint survey, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility, which included ongoing compliance with all financial obligations for the delivery of care. a. On 03/04/24 at 9:50 A.M. an interview with the Director of Nursing revealed employee payroll checks were not clearing the bank. She stated her paycheck did not clear the last two paydays. She stated she was not leaving (employment) but stated she was only staying because the previous Administrator had quit and she would not do that to the residents. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys in December 2023 and January 2024. He stated on 02/16/24 there was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those were paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) #601, Director of Finances (DOF) #603 and CFO #600 revealed they handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Oakhill Manor. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. He stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 6 of 13 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 03/11/2024 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 He confirmed he had no evidence from the bank that this was a banking error. In addition to the staff payroll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 on this date. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 10:40 A.M. an interview with the Administrator revealed she had just started in the position of Administrator two weeks ago but she was previously the assistant administrator. She stated the corporate office had not given her a reason as to why the staff pay checks were returned for insufficient funds. She stated she does not know if any of the suppliers were being paid, however no suppliers had reached out to her directly in the last two weeks stating they had not been paid. Staff were to come to her about their paychecks and she was letting the corporate office know their checks did not clear the bank. She stated she was told their money would be wired within 24 hours. On 03/04/24 at 2:45 P.M. an interview with Business Office Manager (BOM) #120 revealed most of the bills were paid through the corporate office. She stated the secretary received the statements then she would give them to her, she would go through them, sort them out, and she would give the ones that needed to be paid to the Administrator and she wound send them to the corporate office to be paid. She stated Physician #130 and #131 had come to her asking about payment and she had to reached out the corporate office; however, they said they would take care of it but it never got done. She stated she also was responsible for completing employee payroll. She stated on 02/16/24 the facility had 43 staff members ( STNA #100, #103, #105, #106, #107, #116, #210, #211, #212, #215, #216, #220, #224, #225, #227, #229, #231, #232, #235, #236, LPN #109, #213, #214, #223, #226, #237, Dietary #122, #123, #124, #222, #228, #230, #233, #234, BOM #120, Social Service #217, Housekeeping #118, #119, #126, Marketing #121, Hospitality Aide #219, Maintenance #113 and #218) whose checked did not clear the bank. She stated they had all since been paid but there was a delay in payment. She stated the staff were told to bring her the documentation for the fees they received and they would also be paid. An email from the Administrator dated 03/07/24 at 3:08 P.M. revealed the facility had 23 staff (STNA #101, #102, #212, #224 #242, LPN #125, #223, #237, #240, Dietary #123, #228 , #233, Housekeeping #118, #126, #243, Maintenance #113, #121, Activity #112, #241, Administrator #500, #501, Receptionist #117 and Social Service #217) whose checks where returned for insufficient funds from the 03/01/24 payday. b. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: On 03/04/24 at 10:50 A.M. an interview with Pest Control Service #133 revealed the facility was behind from October 2023 through the present day in the amount of $810.00. She stated since the new company had taken over, they had not paid any invoices for service at all. Review of the invoices from Anova Psychiatric Services and Physician #130 revealed the facility was billed $500.00 on each month for 04/25/23, 05/25/23, 06/24/23, 07/25/23, 09/25/23 and 10/25/23 for a total of $3000.00. The Administrator did not have the most current invoices. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 7 of 13 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 03/11/2024 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 On 03/04/24 at 10:54 A.M. an interview with Physician #130 (Anova Psychiatric Services) revealed he has not been paid for almost a year. He stated he received a paper check in November 2023; however, it was returned for insufficient funds. He stated he had called the corporate office in Florida but just gets the run-a-around. He stated although he had no plans to discontinue service as of this date, he hoped the company resolved the issue soon. Residents Affected - Many Review of the check written on 03/04/24 revealed the facility sent a check to Physician #130 for $3000.00 to pay invoices from 04/25/23 through 10/25/23. On 03/04/24 at 11:05 A.M. an interview with Sanitation #213 revealed the facility was 30 days past due with their account. On 03/04/24 at 11:50 A.M. an interview with City Water Company Office Manager #134 from Barnesville water revealed the facility had a past due amount of $3345.82 with a current bill of $6420.97 which included the past due and current bill. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023; however, CFO #600 reported the facility would be sending out checks this week. Review of the email from Broad River Therapy Services dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $103,531.89. They had a statement from 11/02/23 with a due date of 12/02/23 which was 94 days past due for $27,252.19, a statement for 12/01/23 with a due date of 12/31/23 which was 65 days past due for $28291.58, a statement for 01/02/24 with a due dated of 02/01/24 which was 33 days past due for $22,527.73 and a statement for 02/02/24 with a due date of 03/03/24 which was two days past due for $25,461.39. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24. Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services. Review of the invoices from the Medical Director (Physician #131) revealed the facility was billed $2000.00 on 12/11/23, 01/10/24, 02/01/24 and 02/28/24 for a total of $8000.00 owed. On 03/04/24 at 2:04 P.M. an interview with Medical Director Office Manager #132 revealed the facility was charged $2000.00 a month for Medical Director services and had not paid in four months. She stated they have an outstanding bill of $8000.00 as of 03/04/24. Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 8 of 13 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 03/11/2024 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 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. The governing body consisted of Chief Financial Officer #600, Chief Executive, Officer #601, and Chief Nursing Officer/Compliance Officer #602. 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. Review of the administrator job description revealed they would operate the facility in accordance with the established policies and procedures of the facility. The job description indicated the administrator would supervise the recruitment, employment and discharge of staff. And work closely with the DON to assure there were adequate numbers of staff to meet the needs of each resident and to comply with the state of Ohio licensure law. The administrator would act as a liaison with the facility owners and the medical, nursing, and other supervisory staff through regular meetings. This deficiency represents non-compliance investigated under Complaint Number OH00151616. This deficiency is also an example of continued non-compliance from the survey dated 01/31/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 9 of 13 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 03/11/2024 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 41. Residents Affected - Many Findings include: Review of the facility survey history revealed on 12/18/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. An interview 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. At the time of the survey, the Administrator did not provide any additional information as to why payroll was not met for these employees on this date. This payroll issue was in addition to the identification of other vendors/suppliers with past due balances, non-payment and shut off notices being issued to the facility. Following the 12/18/23 survey, the facility provided evidence of payments being made to various different supplies/vendors removing the likelihood of situations of neglect and the resolution of shut off notices for the facility. However, at the time of this complaint survey, the facility failed to ensure their governing body was effective in establishing and implementing policies regarding the management and operation of the facility and the Quality Assurance Performance Improvement Program provided continual monitoring, which included ongoing compliance with all financial obligations for the delivery of care regarding payroll, therapy services and electricity. During the onsite investigation, completed on 03/11/24 continued concerns related to financial solvency and the lack of effective QAPI program were identified: a. On 03/04/24 at 9:50 A.M. an interview with the Director of Nursing revealed employee payroll checks were not clearing the bank. She stated her paycheck did not clear the last two paydays. She stated she was not leaving (employment) but stated she was only staying because the previous Administrator had quit and she would not do that to the residents. On 03/04/24 at 9:57 A.M. an interview with CFO #600 revealed his corporation had more issues with banking since the previous two surveys in December 2023 and January 2024. He stated on 02/16/24 there was an error with their Positive Pay system (an automated cash-management service used by financial institutions where checks issued by companies are matched with those presented for payment). CFO #600 stated they placed the check numbers into the system and uploaded it from the Human Resource file to the bank and those were paid by the bank. He stated they covered the wire fees and bounced check fees as soon as the employee updated them on the amounts. An additional interview on 03/04/24 at 10:35 A.M. with CFO# 600 revealed, Chief Executive Officer (CEO) #601, Director of Finances (DOF) #603 and CFO #600 revealed they handled all the financial responsibilities for this facility and two sister facilities, Astoria Place of Cambridge, and Oakhill Manor. He confirmed he was aware the payroll checks from 03/01/24 were returning for insufficient funds for all three facilities. He stated they (Epic Corporation) used the same bank for all the payroll and wired transfers. He stated each facility had its own accounts to pay for payroll and to pay their suppliers. He stated on 02/16/24 there was a Positive Pay file error (they place a restricted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 10 of 13 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 03/11/2024 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many range of check numbers in the account for the checks to be cashed to match the HR files and only those check would clear). He stated there was a mix-up with the numbers so all the checks were rejected. He confirmed he had no evidence from the bank that this was a banking error. In addition to the staff payroll issues, he stated the corporation had placed Physician #130 on a payment plan to get him caught up with monies due and had just sent Physician #130 a check for $6000.00 on this date. He stated he would stay in communication with the other providers the facility used and would never let the bills get to the point of a provider termination of service. He stated he was working with all the staff at the facility to get them paid. He was unable to answer the question as to why payment plans that either himself, Chief Executive Officer (CEO) #601 or Director of Finance #603 initiated, were not followed through with and why payments were missed. On 03/04/24 at 10:40 A.M. an interview with the Administrator revealed she had just started in the position of Administrator two weeks ago but she was previously the assistant administrator. She stated the corporate office had not given her a reason as to why the staff pay checks were returned for insufficient funds. She stated she does not know if any of the suppliers were being paid, however no suppliers had reached out to her directly in the last two weeks stating they had not been paid. Staff were to come to her about their paychecks and she was letting the corporate office know their checks did not clear the bank. She stated she was told their money would be wired within 24 hours. On 03/04/24 at 2:45 P.M. an interview with Business Office Manager (BOM) #120 revealed most of the bills were paid through the corporate office. She stated the secretary received the statements then she would give them to her, she would go through them, sort them out, and she would give the ones that needed to be paid to the Administrator and she wound send them to the corporate office to be paid. She stated Physician #130 and #131 had come to her asking about payment and she had to reached out the corporate office; however, they said they would take care of it but it never got done. She stated she also was responsible for completing employee payroll. She stated on 02/16/24 the facility had 43 staff members ( STNA #100, #103, #105, #106, #107, #116, #210, #211, #212, #215, #216, #220, #224, #225, #227, #229, #231, #232, #235, #236, LPN #109, #213, #214, #223, #226, #237, Dietary #122, #123, #124, #222, #228, #230, #233, #234, BOM #120, Social Service #217, Housekeeping #118, #119, #126, Marketing #121, Hospitality Aide #219, Maintenance #113 and #218) whose checked did not clear the bank. She stated they had all since been paid but there was a delay in payment. She stated the staff were told to bring her the documentation for the fees they received and they would also be paid. An email from the Administrator dated 03/07/24 at 3:08 P.M. revealed the facility had 23 staff (STNA #101, #102, #212, #224 #242, LPN #125, #223, #237, #240, Dietary #123, #228 , #233, Housekeeping #118, #126, #243, Maintenance #113, #121, Activity #112, #241, Administrator #500, #501, Receptionist #117 and Social Service #217) whose checks where returned for insufficient funds from the 03/01/24 payday. b. In addition to the facility's failure to ensure payroll obligations were met and continued to be met to ensure the ongoing effective day to day operation of the facility the following vendors/suppliers were reviewed as part of the State agency investigation with concerns identified: On 03/04/24 at 10:50 A.M. an interview with Pest Control Service #133 revealed the facility was behind from October 2023 through the present day in the amount of $810.00. She stated since the new company had taken over, they had not paid any invoices for service at all. Review of the invoices from Anova Psychiatric Services and Physician #130 revealed the facility was billed $500.00 on each month for 04/25/23, 05/25/23, 06/24/23, 07/25/23, 09/25/23 and 10/25/23 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 11 of 13 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 03/11/2024 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 0865 a total of $3000.00. The Administrator did not have the most current invoices. Level of Harm - Minimal harm or potential for actual harm On 03/04/24 at 10:54 A.M. an interview with Physician #130 (Anova Psychiatric Services) revealed he has not been paid for almost a year. He stated he received a paper check in November 2023; however, it was returned for insufficient funds. He stated he had called the corporate office in Florida but just gets the run-a-around. He stated although he had no plans to discontinue service as of this date, he hoped the company resolved the issue soon. Residents Affected - Many Review of the check written on 03/04/24 revealed the facility sent a check to Physician #130 for $3000.00 to pay invoices from 04/25/23 through 10/25/23. On 03/04/24 at 11:05 A.M. an interview with Sanitation #213 revealed the facility was 30 days past due with their account. On 03/04/24 at 11:50 A.M. an interview with City Water Company Office Manager #134 from Barnesville water revealed the facility had a past due amount of $3345.82 with a current bill of $6420.97 which included the past due and current bill. On 03/04/24 at 11:57 A.M. an interview with Broad River Therapy Office Manager #128 revealed they had not received payment from the facility since September 2023; however, CFO #600 reported the facility would be sending out checks this week. Review of the email from Broad River Therapy Services dated 03/06/24 at 8:48 A.M. revealed the facility had a past due amount of $103,531.89. They had a statement from 11/02/23 with a due date of 12/02/23 which was 94 days past due for $27,252.19, a statement for 12/01/23 with a due date of 12/31/23 which was 65 days past due for $28291.58, a statement for 01/02/24 with a due dated of 02/01/24 which was 33 days past due for $22,527.73 and a statement for 02/02/24 with a due date of 03/03/24 which was two days past due for $25,461.39. The facility utilized a contracted service for the services of a dietitian. Review of the invoice from Nutritech Consulting Services dated 02/01/24 revealed the facility owed $1,645.00 and the due date was 02/10/24. This had been received by the facility and scanned to the corporate office on 02/02/24. Interview on 03/04/24 at 12:39 P.M. with Dietitian #135 revealed she was the owner of the nutrition services company that provided services to the facility. She stated due to previous concerns of not receiving payment, she required the facility to pre-pay for her services. Dietitian #135 stated she had terminated services on 03/01/24 as the facility was 23 days behind on their pre-pay plan. She stated CFO #600 called on 03/04/24 and paid the February 2024 balance of $1,645.00 so services would resume. The facility had until 03/10/24 to pre-pay for the March 2024 services. A follow-up interview on 03/11/24 with Dietitian #135 revealed if the facility did not make additional payment in full on this date, she would have to terminate services. Review of the invoices from the Medical Director (Physician #131) revealed the facility was billed $2000.00 on 12/11/23, 01/10/24, 02/01/24 and 02/28/24 for a total of $8000.00 owed. On 03/04/24 at 2:04 P.M. an interview with Medical Director Office Manager #132 revealed the facility was charged $2000.00 a month for Medical Director services and had not paid in four months. She stated they have an outstanding bill of $8000.00 as of 03/04/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 12 of 13 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 03/11/2024 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 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility policy dared February 2020 titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. This deficiency represents non-compliance investigated under Complaint Number OH00151616. This deficiency is also an example of continued non-compliance from the survey dated 01/31/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366261 If continuation sheet Page 13 of 13