Health inspection·February 20, 2020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a plan of care was developed to address the care and treatment of a stage IV pressure ulcer for one (#39) of one resident reviewed for pressure ulcers. The facility identified four residents identified with pressure ulcers. The facility census was 44. Findings including: Review of the medical record revealed Resident #39 admitted to the facility on [DATE]. Diagnoses included stage IV coccygeal pressure ulcer, arthritis, atrial fibrillation, pacemaker, congestive heart failure, cerebral vascular accident, glaucoma, and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/20, revealed Resident #39 had the ability to make needs known, had moderate cognitive impairment, was dependent on two staff for the completion of activities of daily living including bed mobility and transfer, was incontinent of bowel and bladder, and receiving treatment for a stage IV pressure ulcer. Review of the 12/18/19 skin assessment revealed the resident was at risk for skin breakdown. Review of a skin assessment dated [DATE] documented the resident was admitted with a stage IV pressure ulcer to the coccyx measuring 3 centimeters (cm) by 4 cm by 2.5 cm deep with tunneling. Review of the wound center evaluation dated 02/17/20 revealed the wound was post debridement measuring 5 cm by 5.5 cm by 2.5 cm. Large serosanguinous drainage with mild odor was noted and a culture was taken. The medical record contained no plan of care addressing the care and treatment of Resident #39's stage IV pressure ulcer. Interview on 02/20/20 at 2:15 P.M. the Director of Nursing verified no nursing plan of care was developed to address the stage IV pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 2 of 7 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 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of St. Francis 930 South Wynn Road Oregon, OH 43616 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to follow physician orders and facility policy to change the peripherally inserted central catheter(PICC) dressings every seven days for one (#46) of one resident reviewed for PICC lines. The facility identified two residents with PICC lines. The facility census was 44. Residents Affected - Few Findings include; Review of the medical record revealed Resident #46 admitted to the facility on [DATE]. Diagnoses included pneumonia, pulmonary embolism, malignant neoplasm of pancreas, type 2 diabetes mellitus, severe protein calorie malnutrition, chronic kidney disease, anemia, cardiomegaly, and pulmonary hypertension. Review of the Minimum Data Set assessment, dated 02/06/20, the resident was identified as alert, oriented, able to make needs known, dependent on staff for the completion of activities of daily living, and receiving intravenous (IV) medications. Review of hospital discharge orders dated 01/25/20 the resident was to have a PICC line left in place. Review of the plan of care dated 01/30/20 revealed a care plan for the PICC line and the use of IV antibiotic medications being administered related to infections. Interventions included: Will not have any complications related to IV therapy, Check dressing at site daily, if IV is infiltrated: stop infusion and thoroughly examine the site, Monitor/document/report to physician signs and symptoms of infection at the site: drainage, inflammation, swelling, redness, and warmth. Review of physician order revealed on 02/05/20 the physician ordered the PICC line dressing to be changed with injection ports once a week,every seven days. Review of the medical record revealed no evidence of any PICC line dressing changes since 02/05/20. Observation on 02/18/20 at 10:21 A.M. revealed Resident #46 was noted with a double lumen PICC line to the right upper arm. The transparent semi-permeable membrane dressing was dated 02/05/20 and peeling off. Interview on 02/18/20 at 6:20 P.M., Licensed Practical Nurse (LPN) #311, during observation of Resident #46, verified the PICC line dressing was dated 02/05/20 and peeling from the site. LPN #311 verified the dressing was to be changed every seven days in accordance with facility policy and/or physician orders. Interview on 02/19/20 06:10 A.M. the Director of Nursing confirmed the dressing change should have been conducted every seven days. The order was not entered correctly and the dressing had not been completed since 02/05/20. Review of the facility policy titled Central Venous Catheter Dressing Change, revised April 2016, indicated transparent semi-permeable membrane dressings are to be changed at least every five to seven days and as needed (when wet, soiled, or not intact). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 3 of 7 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 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of St. Francis 930 South Wynn Road Oregon, OH 43616 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 pressure relieving mattress was placed on the proper settings and failed to acquire equipment to follow physician orders for treatment of a stage IV pressure ulcer for one (#39) of one resident reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 44. Residents Affected - Few Findings including: Review of the medical record revealed Resident #39 admitted to the facility on [DATE]. Diagnoses included stage IV coccygeal pressure ulcer, arthritis, atrial fibrillation, pacemaker, congestive heart failure, cerebral vascular accident, glaucoma, and osteopenia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/20, revealed Resident #39 had the ability to make needs known, had moderate cognitive impairment, was dependent on two staff for the completion of activities of daily living including bed mobility and transfer, was incontinent of bowel and bladder, and receiving treatment for a stage IV pressure ulcer. Review of the 12/18/19 skin assessment revealed the resident was at risk for skin breakdown. Review of a skin assessment dated [DATE] documented the resident was admitted with a stage IV pressure ulcer to the coccyx measuring 3 centimeters (cm) by 4 cm by 2.5 cm deep with tunneling. Review of physician orders revealed on 12/26/19 the physician ordered an alternating air mattress to be applied to the bed. No documentation was provided indicating when the air mattress was placed in use. Review of wound center documentation on 01/13/20 the resident was evaluated for a stage IV pressure ulcer to the coccyx. The wound was described as measuring 4.7 long by 5.2 cm wide by 4.3 cm deep with a large amount of serosanguinous drainage. The physician ordered to cleanse the coccyx with liquid antibiotic soap and water and rinse well. The dressing orders included a debriding agent of 0.125% Dakins solution applied to a moist to moist dressing and change twice daily. Review of wound center documentation on 02/03/20 the residents stage IV coccygeal pressure ulcer was evaluated. The wound was described as measuring 4.4 cm long by 6.2 cm wide by 4.5 cm deep with a large amount of serosanguinous drainage post debridement. The physician documented to check with facility regarding wound vacuum placement. bid. Review of wound center documentation on 02/17/20 noted the coccyx wound to the cleansed with liquid antibiotic soap and water rinse well. The wound dressing was to change to a KCI wound vacuum (facility to apply today), drape wound with KCI film, place white foam over exposed bone then fill with black foam. Apply positive bolster around wound, bridge hip (make sure there is KCI film under black foam of bridge) and set at 150 millimeters of mercury (mmHg) continuous pressure. Change the dressing Monday, Wednesday, and Friday Dietician to follow low pre-albumin and large draining wound. The area measured 5 cm by 5.5 cm by 2.5 cm with large amount of serosanguinous drainage with mild odor. Review of the resident's weights revealed the resident weighed 125 pounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 4 of 7 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 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of St. Francis 930 South Wynn Road Oregon, OH 43616 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 02/18/20 at 5:10 P.M. revealed the resident was in bed with an air mattress on and settings display at 16. On 02/19/20 at 6:30 A.M. resident in bed with air mattress setting at 16. Interview with the Assistant Director of Nursing #1 on 02/19/20 at 7:15 A.M. revealed the facility did not have a copy of the alternating air mattress manufacturer directions for use and the durable medical equipment company would be contacted. Review on 02/19/20 at 8:40 A.M. of the air mattress pressure redistribution operating instructions revealed patient set-up requires the bed setting to be coordinated with the resident's weight. Observation on 02/19/20 at 2:45 P.M. noted Registered Nurse (RN) #312 and RN #313 to complete a dressing change. They applied the debriding agent 0.125% Dakins solution to a moist to moist dressing and placed to the pressure ulcer. Interview at the time of the observation on 02/19/20 at 2:45 P.M. with RN #312 confirmed the wound vacuum had not been delivered to the facility and she was informed to continue the previous dressing change. Further interview revealed RN #312 and RN #313 were not able to operate or verify the settings on the air mattress were appropriate for Resident #39. Observation on 02/20/20 at 7:00 A.M. revealed Resident #39 to be in bed with the air mattress set at 13. Interview on 02/20/20 8:30 A.M. the Director of Nursing (DON) revealed she was unaware of the operation of the air mattress and the setting requirements according to the resident's weight. The DON indicated her follow-up noted the bed was set at 16, which was for a person weighing 150 pounds. Resident #39's current weight was 125 pounds and the bed should be set at 13. The bed was set-up by the durable medical equipment company and nursing staff were unaware how to operate or verify the correct settings were in place for Resident #39's specific needs. Additionally, the resident's wound vacuum was still unavailable at the time of the interview and the durable medical equipment company had not returned previous telephone calls. Interview on 02/20/20 at 10:51 A.M. with DON revealed the facility was still waiting for the wound vacuum to be delivered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 5 of 7 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 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of St. Francis 930 South Wynn Road Oregon, OH 43616 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 interview, and review of facility policies, the facility failed to reassess a resident who demonstrated a significant weight loss. This affected one (#28) of two reviewed for nutrition. The facility identified three residents with unplanned significant weight loss. The facility census was 44. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date of 12/22/16. Diagnoses included Down's syndrome, abnormal posture, dementia, peripheral vascular disease, dysphagia, hallucinations, seizures, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/20, revealed Resident #28 was rarely or never understood. Resident #28 required extensive assistance for bed mobility, transfer, locomotion, dressing, eating, toilet us and personal hygiene. Resident #28 displayed no behaviors during the review period. Resident #28 held food in her mouth/cheeks or had residual food in mouth after meals. Resident #28 had no significant weight changes during the review period. Resident #28 had a mechanically altered diet. Review of Resident #28's care plan revised 01/16/20 revealed supports and interventions of self-care deficit and risk for altered nutrition. Review of Resident #28's weights revealed on 01/21/20 Resident #28 weighed 132 pounds (lbs). On 02/04/20 Resident #28 weighed 123 lbs. This was a 6.8% weight loss in fourteen days. On 02/19/20 Resident #28's weight was documented as 125 lbs. Review of Resident #28's nutritional assessment dated [DATE] revealed Resident #28 received a regular diet with ground meat and small portions. Resident #28's average intake was 50% to 100%. Resident #28 was to have a divided plate and a lidded double handled cup. Resident #28's weight and meal intakes were stable at the time of the assessment. There were no further assessments addressing Resident #28's nutritional assessment. Review of Resident #28's progress notes found no documented notifications were made to the physician or the dietician regarding Resident #28's significant weight loss. Interview on 02/19/20 at 10:07 A.M. with State Tested Nursing Assistant (STNA) #200 revealed Resident #28 was not able to make her needs known and required physical assistance with eating. STNA #200 reported Resident #28 was weighed monthly and Resident #28's February 2020 weight showed a weight loss from her January 2020 weight. STNA #200 reported the loss was reported to the nurse who requested Resident #28 to be reweighed on 02/19/20. STNA #200 was not aware of any supplements or dietary changes made related to the weight loss. STNA #200 reported no weights were taken between the 02/04/20 and 02/19/20. Interview on 02/19/20 at 10:24 A.M. with Licensed Practical Nurse (LPN) #310 verified she was aware Resident #28 had significant weight loss of nine pounds on 02/04/20. LPN #310 reported Resident #28 was reweighed today, 02/19/20, and was 125 lbs. which was a two pound increase but still a significant weight loss from Resident #28's 01/21/20 weight. LPN #310 verified no notifications were made (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 6 of 7 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 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Gardens of St. Francis 930 South Wynn Road Oregon, OH 43616 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 and stated getting a dietary consult would be helpful. Level of Harm - Minimal harm or potential for actual harm Interview on 02/19/20 at 2:55 P.M. with Dietician #420 revealed Resident #28 was last seen by her on 11/07/19 for her quarterly assessment. Dietician #420 reported Resident #28 was on a mechanical soft diet with no ordered supplements. Resident #28's weights were stable at her last evaluation. Dietician #420 reported she was aware Resident #28's weight today 02/19/20 was 125 lbs. Dietician #420 stated she would be addressing the weight change tomorrow. Residents Affected - Few Interview on 02/19/20 at 4:49 P.M. with the Director of Nursing (DON) revealed Dietician #420 was scheduled to review Resident #28 on 02/20/20. Review of the undated facility policy titled Weight Protocol, revealed residents who have experienced unplanned, significant weight loss or gradual weight loss shall be weighed weekly until stable. All monthly weights shall be completed by the fifth of the month and reweights shall be completed by the eight of the month or per facility policy. The legal representative, resident, and physician shall be notified of any significant weight variances per the facility protocol. Review of the undated facility policy titled Guidelines for Completing the Nutrition Assessment Form, revealed a nutrition professional shall complete the Nutrition Assessment form for all residents upon admission, readmission, significant changes in condition, annually and additionally per clinical judgement as part of the Nutrition Care Process. Review of the undated facility policy titled Quarterly Assessments, revealed an assessment reviewing the resident's current nutrition and hydration status shall be completed by the nutrition professional on a quarterly basis or more frequently, directed by the MDS schedule as the resident's condition and/or nutrition and hydration status changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 7 of 7