Inspection·October 6, 2022

F 0569 Review of the resident account list revealed a balance of $1,867.43. Level of Harm - Minimal harm or potential for actual harm Review of the business office file revealed no evidence a spend down letter was issued to Resident #39, or their representative as required. Residents Affected - Some 5. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included hemiplegia, hemiparesis, postural kyphosis. Review of the resident account list revealed a balance of $2,451.37. Review of the business office file revealed no evidence a spend down letter was issued to Resident #47, or their representative as required. Interview on 10/04/22 at 1:30 P.M., with the Finance Manager (FM) #416 verified no spend down letter had been issued to Resident #15, #23, #26, #39, and #47 as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 2 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician communication binder review, physician office staff review, staff interviews and review of facility policy, the facility failed to notify the physician and dietitian of a residents significant weight loss. This affected one (#29) of two residents reviewed for notification of change. The facility census was 66. Findings include: Review of the medical record for Resident #29 revealed an admission date of 07/14/17 and readmission date of 10/18/20. Diagnoses included multiple sclerosis (MS), flaccid hemiplegia affecting right dominant side, dysphagia, conversion disorder with seizures or convulsions, neuromuscular dysfunction of bladder, major depressive disorder, hypertensive heart disease, diverticulosis of large intestine, personal history of transient ischemic attack and cerebral infarction without residual deficits, contracture right hand, chronic migraine and legal blindness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required supervision of eating, was on a mechanically altered diet, had no natural teeth and had no significant weight loss. Review of a plan of care focus area revised 01/19/21 revealed Resident #29 had a nutritional problem related to depression, cardiovascular accident (CVA) and MS. Interventions included administer medications as ordered, assist with meal set-up and meals, diet as ordered, supplements as ordered and monitor/record/report to the physician as needed signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss of 3 pounds in one week, more than 5% in one month, 7.5% in 3 months and 10% in six months. Review of Resident #29's weights revealed on 07/21/22 the Resident weighed 206 pounds, 207.8 pounds on 08/11/22, 196.3 pounds on 09/01/22, 194.0 pounds on 09/22/22 and 190.5 pounds on 09/03/22. Comparison of the weights from 08/11/22 and 09/01/22 confirmed Resident #29 lost 11.5 pounds, indicating a significant weight loss of 5.5%. Comparison of weights from 08/18/22 and 09/22/22 confirmed resident had a weight loss of 13.3 pounds, indicating a significant weight loss of 6.4% in a month. Finally, comparison of weights dated 07/21/22 and 09/30/22 confirmed Resident #29 lost 15.5 pounds, indicating a significant weight loss of 7.5% within three months. Review of progress notes from 08/11/22 through 10/04/22 revealed no documentation Resident #29's physician had been notified of the Resident's significant weight loss. Interview on 10/05/22 at 7:25 A.M., with Unit Manager (UM) #467 confirmed Resident #29 had some weight loss. UM #467 verified there was no documentation in Resident #29's electronic medical record (EMR) the physician or dietitian had been notified of the significant weight loss. Interview on 10/05/22 at 10:05 A.M., with Licensed Practical Nurse (LPN) #445 revealed nursing staff generally faxed any resident concerns to the physician. A copy of the faxed communication was kept in a physician communication binder. In addition to no evidence documented in Resident #29's EMR, LPN #445 verified the physician communication binder contained no evidence the physician had been notified of the resident's significant weight loss. LPN #445 stated the facility had to have notified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 3 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the physician of the weight loss because laboratory test (labs) were ordered on 09/02/22. Upon further review of the labs dated 09/02/22, LPN #445 confirmed the labs were ordered due to an irregular blood pressure and pulse and weight loss was not indicated. Review of a neurologist progress note dated 10/03/22, that was provided on 10/05/22 at 4:10 P.M. by the Director of Nursing (DON), revealed Resident #29 had lost 17 pounds between 08/18/22 and 10/03/22. Interview with the DON at this time, stated a physician was notified of the Resident's weight loss. The DON continued to state Resident #29 had a history of weight fluctuations. The DON provided this surveyor with a copy of a nursing progress note dated 08/16/22, which stated nursing left a message for Resident #29's neurologist to call back. The note did not state what this was in regards to. The DON stated the reason for the call to the neurologist was to schedule an appointment, as requested by the attending physician, as the attending physician was aware of Resident #29's weight loss and believed the weight loss had a neurological basis, indicating evidence the attending physician was notified of Resident #29's significant weight loss. This surveyor noted the date nursing contacted the neurologist, 08/16/22, was prior to Resident #29 experiencing a weight loss, with the first significant weight loss documented and identified on 09/01/22. The DON provided a copy of a faxed communication to the physician, dated 09/02/22, as evidence of physician notification of weight loss. The faxed communication was in regards to a swallow study being completed related to a choking incident and did not contain any information related to Resident #29's weight loss. Finally, the DON provided a nursing progress note, dated 09/20/22, which stated Resident #29 did not feel well and the primary care physician was notified. Again, the nursing progress note was silent for attending physician notification of Resident #29's weight loss. Interview on 10/05/22 at 4:46 P.M., with Licensed Dietician (LD) #413 confirmed she had not been notified of Resident #29's weight loss by the facility nursing staff and only became aware of resident weight loss when she reviewed the weekly weight reports. LD #413 stated she was generally the one who notified the facility when there was a significant weight loss. Interview on 10/06/22 1:22 P.M., with the Office Manager (OM) #531 of the attending physician's office revealed Physician #509 was on vacation and unable to be reached this week. While OM #531 stated most communication from the facility came via fax, she was unable to verify if any communication had been sent to Physician #509 regarding Resident #29's significant weight loss. Review of the policy titled Notification of Changes, revised 08/10/22, revealed the facility must consult with the resident's physician when there is a change requiring such notification, including significant changes in a resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status and circumstances requiring a need to alter treatment. Further review revealed, except in emergencies, physician notification would be made within 24 hours of a change occurring in a resident's medical or mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 4 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on review of beneficiary notices and staff interview, the facility failed to ensure advance beneficiary notification of non-coverage (ABN) was provided to residents who remained in the facility following the end of covered Medicare Part A services. This affected two (#29 and #66) of three residents reviewed for beneficiary protection notification. The facility census was 66. Residents Affected - Few Findings include: 1. Review of the beneficiary notice provided to Resident #29 revealed the resident had a facility initiated discharge from Medicare Part A covered services effective 05/20/22. Resident #29 remained in the facility following the end of Medicare Part A coverage. Resident #29 was provided the notice of medicare non-coverage, signed 05/18/22, but was not provided the advance beneficiary notification of non-coverage (ABN). 2. Review of the beneficiary notices provided to Resident #66 revealed the resident had a facility initiated discharge from Medicare Part A covered services effective 03/03/22. Resident #66 remained in the facility following the end of Medicare Part A coverage. Resident #66 was provided the notice of medicare non-coverage, signed 03/01/22, but was not provided the advance beneficiary notification of non-coverage (ABN). Interview on 10/04/22 at 1:28 P.M., with Social Worker (SW) #422 confirmed she provided beneficiary notices upon residents discharge from Medicare Part A services. SW #422 verified Residents #29 and #66 were not provided the ABN when discharged from Medicare Part A Services and stated she was unaware they needed to be provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 5 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a resident's pressure reducing mattress was functioning. This affected one (#65) of one resident reviewed for pressure ulcer prevention. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #65 revealed an admission date of 08/20/20 and a readmission date of 01/09/21. Diagnoses included Parkinson's disease, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), hypotension, dysphagia and unspecified symptoms and signs involving cognitive functions and awareness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 was cognitively intact, required extensive two person assistance with bed mobility and transfers, and extensive one person assistance with dressing, toilet use, and personal hygiene. Additionally, Resident #65 was at risk for pressure ulcers and utilized a pressure reducing device for his bed. Review of a plan of care focus area, revised 06/15/22, revealed Resident #65 was at risk for skin breakdown due to immobility and incontinence. Interventions included alternating pressure mattress (APM) perimeter mattress to bed. Review of a Braden Scale dated 09/03/22 revealed a score of 15, indicating Resident #65 was high risk for developing pressure ulcers. Review of current physician orders for October 2022 revealed Resident #65 had an order for an alternating pressure mattress (APM) perimeter mattress and check for function each shift. Observations on 10/03/22 at 10:07 A.M., 11:37 A.M., 1:31 P.M., 1:47 P.M. and 2:19 P.M., revealed Resident #65 in bed. Resident #65's APM was not functioning. Observation on 10/03/22 at 2:29 P.M., with Licensed Practical Nurse (LPN) #445 of Resident #65's APM perimeter mattress confirmed the mattress was not functioning. LPN #445 verified the APM mattress was not on and Resident #65 was not receiving the therapeutic benefit of the APM mattress. LPN #445 verified Resident #445 was not able to reposition himself in bed and required two staff assistance for repositioning. Additionally, LPN #445 confirmed Resident #65 did not currently have any pressure sores. After attempting to turn the APM mattress on and checking to ensure the mattress was plugged in at the wall, LPN #445 stated she was unsure why the mattress was not functioning and she would have to contact maintenance or the medical supplier. Follow up interview on 10/03/22 at 4:28 P.M., of LPN #445 confirmed maintenance had checked Resident #65's APM mattress and discovered it was unplugged at the unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 6 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of safety data sheets, review of facility list, staff interviews, and policy review, the facility failed to ensure potentially hazardous chemicals were securely stored in the second floor kitchen area. This had the potential to affect four (#12, #14, #15 and #40) residents identified by the facility as cognitively impaired and independently mobile residing on the second floor. Additionally, the facility failed to fall interventions were in place as care planned for fall precautions. This affected one (#32) of three residents reviewed for falls. The facility census was 66. Findings include: 1. Observation on 10/05/22 at 11:10 A.M., of the second floor kitchenette revealed, in the unlocked cabinet under the kitchen sink, germicidal cleaner and disinfectant spray bottle containing approximately 15 ounces of the cleaner. The bottle had a warning label to avoid contact with eyes; in case of contact, immediately flush with plenty of water; if irritation develops, get medical treatment. Also located in the same unlocked cabinet was a container of Sani-Cloths with bleach. Statements on the container included caution, hazard to humans, causes moderate eye irritation and avoid contact with eyes or clothing. Lastly, located in the unlocked cabinet was a 19 ounce can, approximately half full, of Clorox Disinfecting Spray. Warnings on the Clorox Spray could causes substantial but temporary eye injury and wear protective eyewear. Interview on 10/05/22 at 11:25 A.M., of Housekeeper (HK) #465 and Housekeeper Supervisor (HS) #461 verified the cleaning products located in the unlocked cabinet under the kitchen sink. HS #461 confirmed the cleaning products should be secured and instructed HK #465 to remove the products and store in a locked area. Review of the Safety Data Sheet for Clorox Commercial Solutions Clorox Disinfecting Spray, revised 09/22/15, revealed hazard statements including causes serious eye irritation. Additional review revealed storage precautionary statements included store locked up. Review of the Safety Data Sheet for Germicidal Cleaner and Disinfectant, undated, revealed hazard statements included caused serious eye damage and skin irritation. Further review revealed storage included to keep the product locked up. Review of the Safety Data Sheet, undated, for Sani-Cloth Bleach Germicidal Disposable Wipes revealed precautions for safe handling included avoid contact with eyes, wash hands thoroughly with soap and water after use. Additionally, safety, health, and environmental regulations indicated the product was a pesticide registered by the United States Environmental Protection Agency (EPA) and subject to labeling requirements under federal pesticide lay. Required labeling for the Sani-Cloth Bleach Germicidal Disposable Wipes included the following: hazards to humans and caused moderate eye irritation. Review of the facility provided list revealed four (#12, #14, #15 and #40) residents were identified as being cognitively impaired, independently mobile and residing on the second floor 2. Review of the medical record for Resident #32 revealed an admission date of 06/26/14 and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 7 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some readmission date of 09/27/19. Diagnoses included dementia, hemiplegia and hemiparesis, and unsteadiness on feet. Review of the quarterly MDS dated [DATE] revealed Resident #32 had impaired cognition. Review of the quarterly MDS dated [DATE] revealed Resident #32's cognition was not assessed. Further review revealed she required extensive assistance of one person for transfers, toileting, hygiene, eating and dressing. Continued review revealed she had two or more falls without injury since the previous assessment. Review of the current care plan for Resident #32 revealed she was at risk for falls due to psychoactive drug use, gait/balance problems, diuretic use, hypertension, antihistamine, anti-Parkinson's disease medication, impaired vision, schizophrenia, visual hallucinations and a history of falls. Interventions included signs to remind Resident #32 to use her call light and to ensure her call light was within reach. Review of the Fall Risk Assessment completed 06/20/22 revealed Resident #32 was at high risk for falls. Observation on 10/03/22 at 1:13 P.M., revealed Resident #32 sleeping in her recliner chair. Further observation revealed her call light was on the bed, out of reach. Observation and interview on 10/03/22 at 1:22 P.M. with STNA #423 confirmed Resident #32's call light was out of reach. STNA #423 placed Resident #32's call light within reach at that time. Further interview with STNA #423 confirmed Resident #32 used her call light when she needed assistance. Review of the policy titled Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 8 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of facility policy, the facility failed to ensure the dietitian timely assessed a resident following a significant weight loss and failed to monitor weights as ordered by the physician. This affected one (#29) of three residents reviewed for nutrition. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #29 revealed an admission date of 07/14/17 and readmission date of 10/18/20. Diagnoses included multiple sclerosis (MS), flaccid hemiplegia affecting right dominant side, dysphagia, conversion disorder with seizures or convulsions, neuromuscular dysfunction of bladder, major depressive disorder, hypertensive heart disease, diverticulosis of large intestine, personal history of transient ischemic attack and cerebral infarction without residual deficits, contracture right hand, chronic migraine and legal blindness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact and required supervision of eating, was on a mechanically altered diet, had no natural teeth and had no significant weight loss. Review of a plan of care focus area revised 01/19/21 revealed Resident #29 had a nutritional problem related to depression, cardiovascular accident (CVA) and MS. Interventions included administer medications as ordered, assist with meal set-up and meals, diet as ordered, supplements as ordered and monitor/record/report to the physician as needed signs and symptoms of malnutrition including emaciation, muscle wasting, significant weight loss of 3 pounds in one week, more than 5% in one month, 7.5% in 3 months and 10% in six months. Review of a dietary progress note dated 07/24/22 revealed Resident #29 was on a mechanical soft diet, overall appetite had been good and was offered Boost pudding daily due to history of weight loss. The recommendation was to continue the plan of care goal to maintain weight. Further review of Resident #29's medical record was silent for any dietitian assessments or progress notes after 07/24/22. Review of Resident #29's weights revealed the Resident weighed 206 pounds on 07/21/22, 207.8 pounds on 08/11/22, 196.3 pounds on 09/01/22, 194.0 pounds on 09/22/22 and 190.5 pounds on 09/03/22. Comparison of the weights from 08/11/22 and 09/01/22 confirmed Resident #29 lost 11.5 pounds, indicating a significant weight loss of 5.5%. Comparison of weights from 08/18/22 and 09/22/22 confirmed resident had a weight loss of 13.3 pounds, indicating a significant weight loss of 6.4% in a month. Finally, comparison of weights dated 07/21/22 and 09/30/22 confirmed Resident #29 lost 15.5 pounds, indicating a significant weight loss of 7.5% within three months. The medical record was silent for a weight between 09/01/22 and 09/22/22. Review of current physician orders revealed the following for Resident #29: an order dated 08/07/21 for four ounces of Boost pudding for weight loss in the evening; an order dated 08/07/21 for weekly weight on Thursday; and an order dated 09/30/22 for a pureed texture, honey consistency diet. Review of a Speech and Language Pathologist (SLP) therapy progress note for dates of services from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 9 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/24/22 through 10/06/22 revealed Resident #29 had complaints of decreased appetite, nausea, and difficulties with dentures, with the therapist notifying nursing staff of these concerns and providing education on 08/26/22, 09/02/22, 09/08/22, 09/21/22 and 09/23/22. SLP also reached out to the facility dietitian due to concerns with weight loss the week of 09/19/22. Due to continued concerns with intake, on 08/31/22, SLP recommended a modified barium swallow study (MBSS) be completed. The MBSS was completed on 09/30/22. Interview on 10/05/22 at 10:05 A.M., with Licensed Practical Nurse (LPN) #445 confirmed Resident #29's medical record did not contain weights from 09/01/22 to 09/22/22, verifying weights were not monitored weekly as ordered by the physician. LPN #445 confirmed weights were always documented in the electronic medical record (EMR). Additionally, LPN #445 stated Resident #29 had some issues with his dentures, but they had been sent out for repair and had returned. Interview on 10/05/22 at 4:26 P.M., with Licensed Dietitian (LD) #413 revealed she typically reviewed residents quarterly for nutritional status. LD #413 stated she reviewed weight reports generated from the facility's electronic medical record system on Sundays to determine if there was an abnormality and would then review any resident with weight loss, if needed. While Resident #29 had a history of weight fluctuations, LD #413 stated his weights had been fairly stable over the past year. LD #413 stated she noted this week Resident #29 had a significant weight loss and she intended to see the Resident on 10/03/22 but had gone to another floor and got stuck there, therefore she did not see the resident. On 10/04/22, LD #413 stated she did meet with Resident #29 and the decision was made to keep the Boost pudding one time daily and added Boost Breeze one time daily and a yogurt at one meal each day. LD #413 confirmed Resident #29 had a significant weight loss noted on 09/01/22, 09/22/22 and 09/30/22 and, prior to 10/04/22, she had not assessed Resident #29's nutritional status since 07/24/22. Interview on 10/06/22 at 8:24 A.M., with SLP #520 revealed she had worked with Resident #29 related to swallowing concerns. SLP #520 stated Resident #29's appetite had been a lot lower and he had resistance when he tried to swallow. In addition, Resident #29 had some issues with his dentures, but this was addressed and was no longer a concern. On 08/31/22, SLP #520 made the recommendation for a swallow study to be completed. SLP #520 stated she spoke with several nurses and informed the dietitian via text message, because LD #413 worked a full time day job and was unavailable by phone, of her concerns related to Resident #29's weight loss. SLP #520 stated she did not receive a response from LD #413 when she sent the text message and was unaware if LD #413 reassessed the Resident's nutritional status. Review of the undated policy titled Nutrition and Hydration Intervention Guidelines, revealed nutrition risk factors that indicated the need for a nutritional intervention may include, but not limited to, unfavorable decline in appetite and/or history of reduced appetite, gradual weight loss and/or undesirable significant weight loss of 5% in 30 days, 7.5% in 90 days, and/or 10% in 180 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 10 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents received medications as ordered by the physician. This affected two (#56 and #21) of 12 residents reviewed for medication administration. The facility census was 66. Findings include: 1. Review of the medical record for Resident #56 revealed an admission date of 04/04/14 and a readmission date of 03/01/19. Diagnoses included congestive heart failure, type 2 diabetes mellitus, dependence on renal dialysis, and long term use of insulin. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition and required extensive assistance of one person for bed mobility, dressing, toileting, and hygiene and required limited assistance of one person for transfers, walking, and eating. Continued review revealed she received insulin, an antidepressant, an anticoagulant, a diuretic, and an opioid during the review period. Review of the current physician orders for Resident #56 revealed two orders for cardizem (blood pressure medication) scheduled for hemodialysis days and non-hemodialysis days. A physician order dated 10/02/21 revealed Resident #56 should receive cardizem tablet 30 milligrams (mg), one tablet by mouth four times daily on Tuesday, Thursday, and Saturday. An additional physician order dated 10/03/21 revealed Resident #56 should receive cardizem tablet, 30 mg, give one tablet by mouth four times daily on Monday, Wednesday, Friday, and Sunday; hold if the systolic blood pressure (SBP) is less than 100 or heart rate (HR) is less than 60. Review of the medication administrator record (MAR) for September 2022 for the cardizem order dated 10/02/21 (given on Tuesday, Thursday, and Saturday) revealed Resident #56 did not receive a cardizem dose as ordered on 09/01/22 at 9:00 P.M.; on 09/03/22 at 6:00 A.M., 12:00 P.M., and 5:00 P.M.; on 09/06/22 at 5:00 P.M.; on 09/08/22 at 9:00 P.M.; on 09/10/22 at 5:00 P.M.; on 09/15/22 at 5:00 P.M. and 9:00 P.M.; on 09/17/22 at 6:00 A.M. and 12:00 P.M.; on 09/20/22 at 12:00 P.M., 5:00 P.M., and 9:00 P.M.; on 09/22/22 at 9:00 P.M.; on 09/24/22 at 6:00 A.M., 5:00 P.M., and 9:00 P.M.; on 09/27/22 at 9:00 P.M.; and on 09/29/22 at 5:00 P.M. Review of the MAR for September 2022 and October 2022 for the cardizem order dated 10/03/21 (given Monday, Wednesday, Friday, and Sunday) revealed Resident #56 did not received a cardizem outside the ordered blood pressure parameters on 09/21/22 at 8:00 A.M.; on 09/23/22 at 4:00 P.M.; and on 10/02/22 at 8:00 A.M. Review of the medical record revealed no negative side effects as a result of this deficient practice. Interview on 10/05/22 at 10:35 A.M., with the Director of Nursing (DON) confirmed the cardizem doses were not given per physician's order on the identified dates. 2. Review of the medical record for Resident #21 revealed an admission date of 08/23/18, with the medical diagnoses of Alzheimer's disease, dementia without behavioral disturbance, diverticulitis of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 11 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 the large intestine, and mixed incontinence. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS dated [DATE] revealed Resident #21 had severely impaired cognition and required extensive assistance of one person for toileting and personal hygiene, and supervision of one person for eating. Further review revealed she was dependent for toileting and required substantial/maximal assistance for showers/bathing. Residents Affected - Few Review of the current care plan updated 04/11/22 revealed Resident #21 experienced constipation at times and was at risk for complications. Interventions included providing a stool softener and/or laxative if not having regular bowel movements. Review of the current physician orders revealed an order dated 11/11/20 for docusate sodium capsule (laxative/stool softener), 100 milligrams, give one capsule by mouth every 24 hours as needed for constipation. Review of the bowel/bladder task summary for September 2022 revealed Resident #21 had no bowel movement on 09/22/22, 09/24/22, 09/25/22, 09/26/22, 09/27/22, and 09/28/22. No documentation was recorded on 09/23/22. Review of the MAR for September 2022 revealed docusate sodium was not given at any time, including the dates from 09/22/22 through 09/28/22. Interview on 10/04/22 at 3:47 P.M., with State Tested Nurse Aide (STNA) #423 revealed STNAs were responsible for documenting bowel movements in the electronic medical record (EMR). Further interview revealed nurses track the frequency of residents' bowel movements. Interview on 10/04/22 at approximately 4:30 P.M., with Licensed Practical Nurse (LPN) #478 revealed the EMR alerted nurses when a resident had not had a bowel movement in three days. LPN #478 further revealed she attempted to verify the accuracy of the record by talking with staff or the resident. Continued interview revealed a nurse would provide as-needed medication to treat the constipation after determining the resident had no bowel movement for three days. Interview on 10/05/22 at 2:47 P.M., with the DON confirmed no stool was documented for Resident #21 from 09/22/22 through 09/28/22. Further interview confirmed no as-needed constipation medication was given between 09/22/22 through 09/28/22. Interview on 10/06/22 at 7:07 A.M., with the Administrator revealed the facility had no policy regarding the monitoring of bowel movements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 12 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure residents received sliding scale insulin injections in accordance with the physician's order. This affected one (#56) of 12 residents reviewed for medication administration. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 04/04/14 and a readmission date of 03/01/19. Diagnoses included congestive heart failure, type 2 diabetes mellitus, dependence on renal dialysis, and long term use of insulin. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #56 had intact cognition and required extensive assistance of one person for bed mobility, dressing, toileting, and hygiene and required limited assistance of one person for transfers, walking, and eating. Continued review revealed she received insulin, an antidepressant, an anticoagulant, a diuretic, and an opioid during the review period. Review of the current care plan revealed Resident #56 had type 2 diabetes mellitus. Interventions included administering insulin as ordered. Review of the current physician orders for Resident #56 revealed an order dated 09/15/21 for Humalog KwikPen Solution Pen-injector 100 unit/milliliter (mL) (Insulin Lispro -1 Unit Dial). Inject as per sliding scale: if 90-150 = 3 units subcutaneously before meals for diabetes mellitus. Review of the medication administrator record (MAR) for September 2022 and October 2022 for sliding scale insulin dosing revealed Resident #56 received no insulin on 09/05/22 at 11:00 A.M. when her blood glucose (BG) was 94; on 09/06/22 at 8:00 A.M. when her BG was 111; on 09/11/22 at 8:00 A.M. when her BG was 119; on 09/13/22 at 8:00 A.M. when her BG was 105; on 09/17/22 at 8:00 A.M. when her BG was 130; on 09/18/22 at 8:00 A.M. when her BG was 110; on 09/20/22 at 8:00 A.M. when her BG was 97; on 09/23/22 at 8:00 A.M. when her BG was 100; on 09/28/22 at 8:00 A.M. when her BG was 103; at 11:00 A.M. when her BG was 93; and at 4:00 P.M. when her BG was 132; on 10/01/22 at 8:00 A.M. when her BG was 108; and at 11:00 A.M. when her BG was 135, and on 10/02/22 at 4:00 P.M. when her BG was 132. Review of the medical record revealed no negative side effects as a result of this deficient practice. Interview on 10/05/22 at 10:35 A.M. with the Director of Nursing (DON) confirmed the sliding scale insulin doses were not given per physician's order on the identified dates. Review of the undated facility policy Medication and Treatment Orders revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 13 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 3. Observation on 10/05/22 at 11:28 A.M., of the reach in refrigerator and freezer, located in the kitchenette on the second floor, revealed an opened container, approximately one-third full, of prune juice dated 06/25/22 and had an expiration date of 09/18/22; an opened and undated container of cranberry juice cocktail, approximately one-quarter full; an opened and undated approximately three-quarter full container of orange juice; a second opened and undated container of prune juice, approximately three-quarters full; and an opened and undated container of apple juice, approximately three-quarters full. The freezer contained two bags of opened, unsealed and undated packages of french toast sticks. Ice crystals were observed on the french toast sticks. In addition, there were four frozen waffles in a plastic bag. The package was unlabeled and undated. Ice crystals were observed on the waffles. Observation of a sign on the freezer door, dated 11/09/15, stated Please make sure that any food stored in this refrigerator or freezer is labeled and dated. Anything not properly labeled and dated will be disposed of. Interview on 10/05/22 at 11:35 A.M., of Dietary Aide (DA) #425 confirmed the refrigerator and freezer were used to store foods used by the residents and verified the above findings. DA #425 stated he believed the opened containers of juice were good to use until the use by date, regardless of the date the juice was opened. DA #425 removed the opened, undated and unlabeled items from the refrigerator and freezer and disposed of them in the trash. DA #425 stated the staff knew everything needed to be labeled and dated. Review of undated policy titled Refrigerated Storage, revealed refrigerated items should have a label indicating name and date product was received, used, or first opened. Review of the undated policy titled Visitors Providing Food to Residents revealed perishable food items shall be labeled, dated and placed in appropriate storage area (e.g., personal or unit refrigerators) in such a way to clearly distinguish it from food used by or prepared by the facility. Based on observation, staff interviews and review of facility policies, the facility failed to ensure foods were labeled, dated and stored in accordance with professional standards for food services safety. This had the potential to affect all residents in the facility except two (#61 and #65) residents who were identified as receiving no food by mouth. The facility census was 66. Findings include: 1. Observations and concurrent interview with Dietary Director #484 on 10/03/22 at 8:42 A.M., revealed an open box of hamburgers in the freezer with the plastic bag open to air. Further observations revealed a bag of salami dated 09/01/22, a bag of turkey lunch meat dated 09/14/22, a bag of hot dogs dated 09/22/22, and a bag of sliced ham lunch meat dated 09/26/22. Interview at that time, with the Dietary Director #484 confirmed the lunch meat and hot dogs had been opened and should have been discarded within seven days of the date written on the bag. 2. Observation and concurrent interview on 10/05/22 at 11:05 A.M., with Licensed Practical Nurse (LPN) #429 revealed the refrigerator on the 300-hall was designated for resident food and contained unlabeled, undated Chinese food; unlabeled and undated chili; and an unlabeled and undated open jar of pizza sauce. LPN #429 confirmed the unlabeled, undated food items. Observation of the sign on the front of the refrigerator stated, Please make sure that any food stored in this refrigerator or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 14 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some freezer is labeled and dated. Anything not properly labeled and dated will be disposed of. The sign was dated 11/09/15. Observation and concurrent interview on 10/06/22 at 11:19 A.M., with State Tested Nurse Assistant (STNA) #500 revealed the resident's food refrigerator on the 300-hall contained opened cartons of thickened cranberry juice, prune juice, thickened water, thickened apple juice, orange juice, and tomato juice were unlabeled and undated. Further observation and interview confirmed an opened carton of thickened water was dated 09/24/22. Interview on 10/06/22 at 1:16 P.M., with the Dietary Director #484 revealed opened food should be labeled on the date it was opened, and should be consumed or discarded within seven days unless the product had an earlier expiration date. He further clarified day one was the first day it was labeled. Continued interview revealed bulk beverages, such as prune juice and thickened water, should also be consumed within seven days of opening, or discarded. The Dietary Director #484 stated he did not have a policy stating this guideline, but stated it was a standard of care per ServSafe (nationally recognized food safety guidance). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 15 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to maintain complete and accurate medical records regarding fall incidents. This affected three residents (#32, #34, and #53) of three residents reviewed for falls. The facility census was 66 residents. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 11/01/18 and a readmission date of 08/19/22. Diagnoses included broken internal right hip prosthesis (08/19/22), need for assistance with personal care, unspecified dementia, and muscle weakness. Review of the 5-day minimum data set (MDS) dated [DATE] revealed Resident #53 had intact cognition, required extensive of two people for bed mobility, transfers, dressing, toilet and hygiene, and required supervision with setup help only for eating. Further review revealed she used a wheelchair for mobility, and she had a fall in the month prior to reentry. Review of Resident #53's Fall Risk Assessment revealed it was created on 08/16/22 at 9:00 A.M. regarding a fall from 08/15/22 and Resident #53 was at moderate risk for falls. Further review revealed nothing regarding the circumstances of the fall, any notifications, or any newly developed interventions. Review of the incident log dated 04/01/22 to 10/03/22 revealed Resident #53 fell on [DATE] at 9:00 A.M. Further review of the incident log revealed a statement at the bottom of the document Privileged and Confidential - Not part of the Medical Record - Do not Copy. Review of the progress notes for Resident #53 dated 08/11/22 through 08/20/22 revealed no reference to a fall. Review of a progress note dated 08/15/22 revealed Resident #53 had a right hip fracture, required surgery, and would be admitted to the hospital. Interview on 10/03/22 at 10:27 A.M., with Resident #53 revealed she fell out of her wheelchair while being pushed down a ramp resulting in a hospitalization, right hip fracture, and surgery. Interview on 10/04/22 at 4:25 P.M., with the Director of Nursing (DON) confirmed the facility did not create progress notes for falls. Further interview revealed information regarding specifics of a fall were documented in a Fall Investigation form located in the Risk Management section of the electronic medical record. The DON confirmed the Fall Investigation form stated at the bottom Privileged and Confidential Not part of the Medical Record - Do not Copy. Interview on 10/05/22 at 8:45 A.M., with LPN #456 revealed she was the nurse for Resident #53 on the day of the fall, 08/15/22. Further interview confirmed Resident #53's progress notes between 08/15/22 and 08/20/22 did not include any reference to a fall. Interview on 10/05/22 at 9:55 A.M., with the DON revealed she could not provide a copy of the Fall Investigation form because it was privileged information. Verbal review of the fall investigation at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 16 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that time revealed Resident #53 was not in the facility at the time of the fall, but was on her way to a meeting in an adjacent building. Another resident was pushing Resident #53 in her wheelchair and lost control of the wheelchair on a ramp. The investigation revealed Resident #53 indicated she leaned too far forward in her wheelchair and subsequently fell out. Resident #53's nurse, LPN #423, was notified and went to the ramp and assessed Resident #53 who reported pain in her right foot and right wrist. Three staff assisted Resident #53 into a wheelchair and returned her to the facility whereupon Resident #53 reported extreme pain, and was subsequently sent to the emergency room. Continued verbal review revealed the resident representative and physician were notified, and an intervention was developed to have staff provide transportation to the meetings in the future, and not allow residents to assist with transportation. Continued interview with the DON at that time revealed the facility used Fall Risk Assessments to document falls. 2. Review of the medical record for Resident #32 revealed an admission date of 06/26/14 and a readmission date of 09/27/19. Diagnoses included dementia, hemiplegia and hemiparesis, and unsteadiness on feet. Review of the quarterly MDS dated [DATE] revealed she had impaired cognition. Review of the quarterly MDS dated [DATE] revealed Resident #32's cognition was not assessed. Further review revealed she required extensive assistance of one person for transfers, toileting, hygiene, eating and dressing. Continued review revealed she had two or more falls without injury since the previous assessment. Review of the Fall Risk Assessment completed 06/20/22 revealed Resident #32 was at high risk for falls. Further review revealed it was created on 06/20/22 at 1:56 A.M. regarding a fall from 06/20/22. Continued review revealed nothing regarding the circumstances of the fall, any notifications, or any newly developed interventions. Review of the progress notes dated 06/20/22 through 06/23/22 revealed no reference to a fall. Review of the incident log dated 04/01/22 to 10/03/22 revealed Resident #32 fell on [DATE] at 1:35 A.M. Further review of the incident log revealed a statement at the bottom of the document Privileged and Confidential - Not part of the Medical Record - Do not Copy. Interview on 10/04/22 at 4:25 P.M., with the DON confirmed the facility did not create progress notes for falls. Further interview revealed information regarding specifics of a fall were documented in a Fall Investigation form located in the Risk Management section of the electronic medical record. The DON confirmed the Fall Investigation form stated at the bottom Privileged and Confidential - Not part of the Medical Record - Do not Copy. Interview on 10/05/22 at 9:50 A.M., with the DON revealed she could not provide a copy of the Fall Investigation form because it was privileged information. Verbal review of the fall investigation at that time revealed Resident #32 was found on the floor next to her bed on 06/20/22 at 1:35 A.M. A physical and neurological assessment was completed with no concerns found. Resident #32 reported no injuries and was assisted back to bed. Resident #32's family was notified, and the physician was notified. Neurological checks were completed for 72 hours. Interventions included a floor mat, and placing the bed against the wall per Resident #32's request. Continued interview with the DON at that time revealed the facility used Fall Risk Assessments to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 17 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document falls. Additionally, Fall Risk Assessments were completed on admission and quarterly, so each Fall Risk Assessment did not reflect a fall. The DON confirmed the Fall Risk assessment dated [DATE] revealed nothing regarding the circumstances of the fall or whether any notifications were completed. Review of the facility policy Falls and Fall Risk, Managing, revised March 2018, revealed no guidance regarding documentation of a fall in the medical record. 3. Review of the medical record for Resident #34 revealed an admission date of 08/17/15, with admitting diagnoses including: hemiplegia and hemiparesis affecting right side; cerebrovascular disease; vascular dementia; peripheral vascular disease; aphasia; epilepsy; type II diabetes; major depressive disorder; chronic kidney disease; acquired absence of right leg above the knee; pulmonary heart disease; weakness and dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had severe cognitive impairment, showed resident had limited function on one side of his body. The Quarterly MDS assessment date 07/16/22 showed the resident had no falls since the prior assessment of 04/19/22. Review of the facility documentation titled Rosary Care Center Incidents By Incident Type from 04/01/22 through 10/03/22 showed Resident #34 had a fall on 08/18/22 at 6:00 A.M. Review of a Fall Risk assessment dated [DATE] revealed Resident #34 scored 17, indicating the Resident was at high risk for falls. Additionally, the risk assessment indicated the reason for the assessment being completed was due to recent falls. The risk assessment did not provide any information related to a specific fall. Review of Electronic Health Record (EHR) and hard copy medical chart for Resident #34 revealed an absence of documentation in the EHR or hard copy medical chart which described the circumstances of the fall, provided details regarding the investigation of the fall completed by the facility, described any resident assessment by qualified medical personnel immediately after the fall, indicated notification to the physician about the fall, or indicated notification to the resident representative about the fall. Observation on 10/03/22 at 10:35 A.M., of Resident #34 revealed the Resident was sitting and positioned appropriately in his wheelchair in the main common area. No safety issues were observed. Interview on 10/03/22 at 1:17 P.M., of Resident #34's family member revealed the resident had fallen out of bed a few times within the last year. Interview on 10/04/22 at 4:19 P.M., with the Director of Nursing (DON) revealed resident fall information was documented in risk management records and was protected information. The DON stated medical record documentation of resident falls was documented on a fall risk assessment, located in the EHR, and confirmed the fall risk assessments did not provide information related to a specific fall, such as a description of the fall, physician notification, resident representative notification, assessment of the resident following the fall or immediate interventions implemented. The DON showed evidence of fall descriptions, interventions, assessments, investigations, and notifications were included in risk management records but this information was not accessible in the residents medical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 18 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Follow up interview on 10/05/22 at 10:10 A.M., with the DON confirmed the EHR and hard copy medical chart for Resident #34 did not contain documentation pertaining to the fall on 08/18/22 which described the circumstances of the fall, described any resident assessment by qualified medical personnel immediately after the fall, indicated notification to the physician about the fall, or indicated notification to the resident representative about the fall. The DON explained information about falls was kept in a Quality Assurance (QA) file, which she reported was not able to be printed for independent review by the survey team. The DON reported the information in the QA file was permitted to be read aloud only and was part of the facility's risk management. Event ID: Facility ID: 366279 If continuation sheet Page 19 of 20 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 366279 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/06/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rosary Care Center 6832 Convent Boulevard Sylvania, OH 43560 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure resident rooms were maintained in good repair. This affected one (#37) of three residents reviewed for environment. The facility census was 66. Findings include: Review of the medical record revealed Resident #37 had an admission date of 05/19/21. Diagnoses included dementia, major depressive disorder, neuromuscular dysfunction of bladder, osteoporosis, peripheral vascular disease, schizoaffective disorder, hypertension, osteoarthritis, psychotic disorder with delusions and overactive bladder. Further review of the quarterly minimum data set assessment dated [DATE] revealed Resident #37's cognition was not assessed. Observation on 10/03/22 at 10:16 A.M., of Resident #37's room revealed the bed pushed against the wall to the right of the entrance to the room. On the wall, near the foot of the bed, were 12 gouges in the drywall, varying in size, and a hole approximately two and one-half inches in diameter and approximately 1/4 to 1/2 inch deep, with crumbled drywall exposed. Interview on 10/03/22 10:36 A.M., of Maintenance Director (MD) #513 and Housekeeping Supervisor (HS) #461 revealed the facility had a work order system, but staff generally called or just told MD #513 if any repairs were needed. MD #513 verified the damage to Resident #37's wall, stating it was quite a divot. MD #513 stated he was unaware of the damage to the wall. HS #461 stated he believed Resident #37's bed was recently moved, possibly over the weekend, and the damage had been caused by the Resident's recliner being against that wall. HS #461 stated since the bed had just been moved, staff did not have time to inform anyone yet of the damage. Interview on 10/03/22 at 10:47 A.M., of Licensed Practical Nurse (LPN) #445 revealed she typically worked on the floor Resident #37 resided on and confirmed the resident was cognitively impaired. LPN #445 stated she was unsure of when Resident #37's bed had been moved to the wall it was currently on but stated it had been moved prior to this past weekend and it may have been a couple of months ago when the bed was moved to that wall. LPN #445 stated she had not noticed the damage to the wall when she was in Resident #37's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366279 If continuation sheet Page 20 of 20