Health inspection·February 1, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 01/30/24 at 8:34 A.M. with State Tested Nurse Aide (STNA) #471 verified Resident #2 had a sign posted on the outside of her door indicating Resident #2 was on a fluid restriction. STNA #471 stated Resident #2 was noncompliant with her fluid restriction so they posted the sign so people entering her room were aware she was on a restriction. Review of the facility policy titled, Dignity, revised February 2021, revealed signs indicating the resident's clinical status or care needs were not to be openly posted. Event ID: Facility ID: 366312 If continuation sheet Page 2 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 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 record review, staff interview, and review of the facility guidelines, the facility failed to issue notifications of the ending of skilled Medicare Part A services for residents who remained in the facility. This affected one (#24) of three residents reviewed for liability notices. The facility census was 52. Residents Affected - Few Findings Include: Review of Resident #24's Beneficiary Notice Form revealed Resident #24 began Medicare Part A skilled services on 07/26/23 and Medicare Part A skilled services ended on 09/21/23. The facility initiated the discharge from services and it was noted Resident #24 remained in the facility. There was no indication Resident #24 or her representative were provided a Notice of Medicare Non-Coverage (NOMNC) or an Advanced Beneficiary Notice of Non-Coverage (ABN). Interview on 01/30/24 at 2:08 P.M. with the Director of Nursing (DON) revealed she confirmed with Licensed Social Worker (LSW) #410 the forms had not been provided. Review of the facility guidelines titled, Beneficiary Notice Guidelines, dated 2021, revealed if the Part A stay ended because the facility determined the beneficiary no longer required daily skilled services and the resident remained in the facility, the facility was to provide a Skilled Nursing Facility Advanced Beneficiary Notice and Notice of Medicare Non-Coverage forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 3 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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, wound treatment management policy, and manufacturer indications for use, the facility failed to ensure skin breakdown treatments were applied as ordered by the physician. This affected one (#19) of one resident reviewed for non-pressure skin impairments. The census was 52. Residents Affected - Few Findings include: Review of the medical record revealed Resident #19 admitted to the facility on [DATE] with the diagnoses including, type II diabetes mellitus with diabetic chronic kidney disease, obstructive and reflux uropathy, anxiety disorder, heart failure, gastroenteritis and colitis, major depression, coronary artery disease, Alzheimer's disease, vascular dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed with moderately impaired cognition, was dependent on staff for activities of daily living (ADLs), required substantial to maximum assistance with side to side positioning, was dependent with transfers, and was assessed at risk for pressure ulcer development with a stage four pressure ulcer (full-thickness skin and tissue loss) present on admission, and moisture associated skin damage (MASD). Review of a pressure sore risk assessment completed on 12/22/23 revealed Resident #19 was assessed at moderate risk of pressure sore development. On 03/28/23 a plan of care addressing Resident #19 risk of developing skin breakdown was revised due to diagnoses of diabetes mellitus, cardiovascular disease, chronic kidney disease, dependence of staff for bed mobility and transfers, and incontinence of bowel. Interventions included to apply protective ointments after incontinent episodes, protect skin on skin between bony prominences, and turn and reposition at regular intervals. In addition, on 06/08/23, a nursing plan was revised due to Resident #19's actual skin breakdown on the coccyx related to MASD with an intervention to perform treatments as ordered. Review of a physician order dated 11/01/24 revealed the physician directed staff to clean Resident #19's sacrum area, make sure the area was dry, and apply Dermaseptine cream (barrier cream to use to prevent irritation due to moisture and promote healing) to the area two times daily for MASD. On 11/22/23 the physician ordered a wound treatment to the left heel including the application of leptospermum honey (MediHoney) three times a week, and cover with a absorbent dressing, and wrap with kerlix. The treatment was to be applied one to three times weekly, and on 12/13/23 the treatment was discontinued. Review of a wound physician evaluation dated 01/23/24 documented Resident #19 with a partial thickness non-pressure wound of the sacrum with an etiology related to moisture associated skin damage, and a duration greater than 207 days. The wound measured 5.0 centimeters (cm) long by (x) 3.5 cm wide x 0.1 cm deep. There were open areas with exposed dermis. Further review revealed treatment included application of Dermaseptine cream twice daily for 30 days. Observation on 01/30/24 at 1:57 P.M. revealed State Tested Nurse Aide (STNA) #456 entered Resident #19's room to complete an incontinence check and reposition the resident. STNA #456 positioned the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 4 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident to the left exposing an area of MASD to the sacrum and obtained a tube of MediHoney. STNA #456 proceeded to apply the MediHoney to the sacrum, positioned the resident, and departed the room. On 01/30/24 at 2:03 P.M. interview with STNA #456 verified no barrier cream (Dermaseptine) was available in Resident #19's room, so MediHoney was used on Resident #19's MASD due to two tubes being available in the room at the bedside. On 01/30/24 at 2:20 P.M. interview with the Director of Nursing (DON) confirmed STNA #456 applied a wound treatment (MediHoney) that was ordered for the treatment of a stage four pressure ulcer to Resident #19's heel and not the physician ordered skin barrier cream (Dermaseptine) that was to be applied to the MASD. The DON additionally verified the MediHoney was a wound treatment to be applied by a licensed nurse. Review of a wound physician assessment dated [DATE] revealed Resident #19 had a partial thickness non-pressure wound of the sacrum with an etiology related to moisture associated skin damage, and a duration greater than 215 days. The wound measured 7.0 cm long x 5.0 cm wide x 0.1 cm deep with open areas of exposed dermis. The treatment included application of Dermaseptine cream apply twice daily for 22 days. Review of the manufacturer indication for Dermaseptine cream revealed the cream was designed to treat skin irritations from incontinence episodes, feeding tube leaks, wound exudates, and perspiration. The cream helped prevent moisture based irritation. Review of the manufacturer indications for leptospermum honey (MediHoney) revealed MediHoney use was for application to wound and burn care. MediHoney supports autolytic debridement and a moist wound healing environment in acute and chronic wound and burns. Review of a wound treatment management policy, revised 11/23/2022, revealed wound treatments will be provided in accordance with physician orders. Dressings will be applied in accordance with manufacturer recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 5 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #8 admitted to the facility on [DATE] with the diagnoses including, generalized osteoarthritis, cerebral infarction, sprain ligaments lumbar spine, wedge compression fracture lumbar vertebra, collapsed vertebra thoracic region, low back pain, displaced fracture of left femur, and osteoporosis. Review of the MDS assessment dated [DATE] assessed Resident #8 with intact cognition, and revealed the resident utilized a wheelchair for mobility propelled by staff and was dependent on staff for activities of daily living (ADL) including sit to stand and chair to bed transfer. On 05/04/23, a nursing plan of care was implemented addressing Resident #8's ADLs deficit related to limited mobility and joint pain due to history of cerebral vascular accident and diagnoses of arthritis and osteoporosis. Further review revealed an updated intervention for staff to utilize a mechanical lift (Hoyer) lift with two staff assistance for transfers. Observation on 01/30/24 at 6:13 A.M. revealed STNA #461 with Resident #8 suspended in a stand-up lift. The resident was unable to stand up right and was slumping to the right while resting on the sling. STNA #461 proceeded to propel Resident #8 in the lift approximately 60 feet down the common hall to the shower room. At 6:20 A.M., an interview with STNA #461 revealed Resident #8 required two staff to assist with transfers and uses a mechanical (Hoyer) lift. STNA #461 confirmed Resident #8 was not safely placed in the stand-up lift and the stand-up lift was not to be used for transporting residents outside their rooms. On 01/30/24 at 6:43 A.M., an interview with the DON verified the stand-up lift was not to be utilized for transferring distances. The DON verified Resident #8 was unable to bear weight and required the use of a Hoyer lift with two staff present for transfers. Review of the Using a Mechanical Lifting Machine policy, revised July 2017, noted at least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the Sit and Stand Lift ([NAME] Flex) instructions for use, dated 2022, revealed the resident must be able to bear weight on at least one leg and have some trunk stability, be able to sit on the edge of the bed to meet criteria for use. Alternative equipment or system shall be used if criteria is not meet. Based on observation, medical record review, hospital document review, staff interview, policy review, and sit-to-stand lift instructions, the facility failed to ensure sufficient fall interventions were put into place to promote resident safety and prevent falls. This resulted in actual harm when Resident #1 fell on [DATE] and sustained a fracture to her right ankle and had a subsequent fall on 01/02/24 and sustained a head laceration which required two staples with no immediate interventions implemented. In addition, the facility failed to ensure transfer equipment was utilized in a safe manner for one (#8) resident. This affected two (#1 and #8) of four residents reviewed for accidents. The facility census was 52. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 6 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0689 Findings Include: Level of Harm - Actual harm 1. Review of Resident #1's medical record revealed an admission date of 05/03/18. Diagnoses included dementia, emphysema, cerebral infarction, hemiplegia and hemiparesis, seizures, anxiety disorder, major depressive disorder, insomnia, and spinal stenosis. Residents Affected - Few Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident #1 was moderately cognitively impaired. Resident #1 required limited assistance of one person for transfers and toilet use. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required set up only with one person assistance for toilet use. Resident #1 required extensive assistance with transfer. Review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 10 indicating Resident #1 continued to be moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #1 displayed no behaviors during the review period. Resident #1 was on hospice at the time of the review and used a wheelchair for mobility. Review of Resident #1's care plan revised 01/24/24 revealed supports and interventions for impaired cognitive function, fall with injury including an ankle fracture on 01/02/24, hospice services for terminal diagnosis of cerebral disease, used antipsychotic medications with risk for adverse reactions, chronic pain, seizure disorder, self-care deficit, and risk for falls. Fall interventions included to anticipate Resident #1's needs, ensure the call light was in reach, provide a safe environment including the bed in low position and personal items in reach, encourage to participate in activities, and ensure the resident wore appropriate footwear. Review of Resident #1's progress notes and fall investigation reports revealed on Saturday, 12/30/23 at 7:27 P.M., it was documented Resident #1 was lowered to the ground by a nurse aide while using the bathroom. Resident #1 had asked for help to the bathroom, and the nurse aide was helping Resident #1 to stand when the resident's legs were shaky, and she could not support herself. The nurse aide lowered Resident #1 to the ground. Resident #1 was assessed with no skin abnormalities were found. Resident #1 reported no pain. Resident #1's physician, family, and management were notified. Further review of the progress notes and fall investigation revealed on Saturday, 12/30/23 at 8:30 P.M., it was noted Resident #1 had an unwitnessed fall in her room. The resident was found lying on her back on the floor in front of her recliner. Resident #1 was unable to bear weight and fell during an unsupervised transfer. Resident #1 denied pain at the time. Resident #1 was assessed with no injuries were found. Neurological checks were initiated. Resident #1 was assisted off the floor, assisted to the toilet, and returned to the recliner. Resident #1 was educated on using the call light for assistance. A fall assessment was completed, and Resident #1 was determined to be a high risk for falls with a score of 12. Review of the previous fall risk assessment from 03/05/23 revealed the resident was assessed at low risk for falls. The interdisciplinary team (IDT) reviewed the fall and it was determined Resident #1 was ambulating on her own and did not ask for assistance. No injuries were found at the time. The new intervention was to refer Resident #1 to occupational therapy (OT) for a toileting program. A moderately cognitively impaired resident was educated on using the call light and no additional immediate interventions were added though Resident #1 had been identified as needing to use the bathroom for both instances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 7 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0689 Review of Resident #1's entire medical record revealed the intervention of OT for a toileting program was never initiated for the resident. Level of Harm - Actual harm Residents Affected - Few Review of progress notes and fall investigation revealed on Monday, 01/01/24, it was noted Resident #1 was found on the floor in her room at 7:28 A.M. by a nurse aide. The fall was not witnessed. Resident #1 was assessed, and an injury was noted on assessment. Notifications were made to Resident's family and physician. Resident #1 was noted to be confused at the time and had a strong odor to her urine. Resident #1 complained of right hip pain, her right foot was observed to be swollen and she had redness to the ankle. In addition, the middle of the right side of her back also had redness and Resident #1 also had a bump to the right side of her head. It was documented Resident #1 was confused, lethargic, had a bruise, and reported pain. Emergency medical service (EMS) was called at 7:33 A.M. and Resident #1 was transferred to the hospital. The IDT team discussed Resident #1's fall from 01/01/24 and it was determined the root cause of the fall was Resident #1 attempted to ambulate on her own, and she lost her balance and had a fall. Notifications were made and Resident #1 was sent to the emergency room (ER) for evaluation. Resident #1 returned from the hospital and Resident #1 was diagnosed with a fracture to the right ankle. Resident #1 was provided a soft cast and was to follow up with orthopedic as soon as possible to have a hard cast put on. Resident #1 was to elevate her right lower leg and be non-weight bearing. Resident #1 was also diagnosed with a urinary tract infection (UTI) and had a new order for the antibiotic Keflex 500 milligrams (mg) three times a day for ten days. Resident #1 received her first dose at the hospital. The noted intervention was sending her to the ER. A fall risk assessment was completed, and Resident #1 was assessed to be at moderate risk for falls with a score of 9. The noted intervention was to send Resident #1 to the ER for evaluation and treatment. In addition, the intervention was to continue Resident #1 on the prescribed the antibiotic. There were no interventions implemented for increased supervision or additional interventions to reduce Resident #1's risk for falls. Review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was seen following a fall for hip pain and altered mental status. Resident #1 was diagnosed with a closed fracture of her right ankle and a urinary tract infection. A new order for Keflex 500 mg one capsule three times a day for 10 days was ordered. The resident's last dosage was at 12:54 P.M. at the hospital. Resident #1 was also provided an occlusal splint (plaster splint roll) for her right ankle. Review of progress notes and fall investigation revealed on 01/02/24, Resident #1 had another unwitnessed fall in her room. Resident #1 was found on her right side up against her bed. Resident #1 was assessed with an injury was noted. Resident #1 was on the floor on her right side with bleeding noted from the back of her head on the right side. Pressure was applied to Resident #1's head to stop the bleeding, and EMS was called. Resident #1's physician and family were notified. Resident #1 could not explain what happened. Resident #1 was sent to the hospital for evaluation and treatment. Resident #1 was noted in her bed prior to the fall and was alert but not completely orientated at the time of the fall. There were no witnesses to the fall. A fall risk assessment was completed, and Resident #1 was found to be at high risk for falls with a score of 16. The IDT met and discussed Resident #1 falls. It was determined the root cause of the fall was due to Resident #1's cognitive decline related to a UTI and weakness. Resident #1 was attempting to get up on her own and lost her balance. The interventions put in place were to send Resident #1 to the emergency room to be evaluate, refer to physical therapy (PT) for strengthening, place the bed in the lowest position when she was in it along with a fall mat next to the bed. On 01/04/24, Resident #1 returned from the hospital and was noted to have had a scalp laceration which required two staples. Review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was admitted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 8 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0689 Level of Harm - Actual harm Residents Affected - Few to the hospital on [DATE]. Resident #1 was admitted with recurrent falls with mild delirium secondary to a UTI and neurological disorder along with a laceration in the back of the head and scalp which required staples. Resident #1 reported she was trying to transfer from her bed into her wheelchair when she fell and hit her head. At the time of Resident #1's discharge from the hospital on [DATE] to return to the nursing home with recommendations for physical therapy. Resident #1 was determined to be a high fall risk and had the barrier to learning of dementia. Resident #1 was orientated to person only. Review of Resident #1's medical record and nurse aide tasks revealed no documentation of two-hour checks completed for toileting, and documentation of two-hour checks for repositioning was not consistent during the review period. Interview on 01/29/24 with Resident #1 found her alert and able to answer basic questions. Resident #1 was not aware she had any falls. Interview on 01/30/24 at 8:31 A.M. with State Tested Nurse Aide (STNA) #471 reported Resident #1 was able to make her basic needs known and required extensive assistance with transfer and toilet use. STNA #471 reported Resident #1 knew when she needed to use the bathroom but was not safe in transferring herself. STNA #471 stated the staff made sure Resident #1 had her call light in reach at all times, but she did not always use it. STNA #471 verified Resident #1 had had a couple falls that resulted in injuries. STNA #471 reported Resident #1 had no other falls since she fell and had to have staples in her head from falling and hitting her head on the bed. STNA #471 reported Resident #1 was declining since the end of December 2023 and was now on hospice. STNA #471 was not sure of the exact day Resident #1 began on hospice, but it was earlier in the month shortly after the resident returned from her hospital stay following her fall. Interview on 02/01/24 at 1:49 P.M. with the Director of Nursing (DON) revealed she was familiar with Resident #1 and her falls. The DON reported in March 2023, Resident #1 was evaluated and determined to be low risk for falls. On 12/30/23, Resident #1 was found on the floor in front of her recliner when the resident attempted to transfer herself. Resident #1 was assessed, and no injury was found. Neurological checks were initiated, and notifications were made. The DON verified the only intervention implemented at the time was education with Resident #1 to use her call light. The DON reported Resident #1 then had another fall on 01/01/24 at 7:28 A.M. when the resident was found by a nurse aide on the floor of her room. Resident #1 was confused, complained of pain, and her right foot was swollen and red. Resident #1 also had a bump on the back of her head. EMS was called and Resident #1 was sent to the hospital. Notifications were made and Resident #1 returned to the facility with a soft cast to her right ankle for a closed fracture, and an order for follow up for a hard cast and an antibiotic for a UTI. The DON reported the interventions put into place included to send Resident #1 to the ER, and when the resident returned to complete the antibiotic for the UTI and refer Resident #1 to OT for a toileting program. The DON verified they were not able to implement the referral to OT prior to Resident #1's fall on 01/02/24 and verified no other fall interventions were implemented. The DON stated on 01/02/24 Resident #1 had another unwitnessed fall in her room when she was found on her right side up against her bed. Resident #1 had a laceration to her head and was complaining of right-sided hip pain. Notifications were made to Resident #1's son and physician and Resident #1 was sent out to the hospital. The DON stated when the resident returned to the facility, she had staples in place to the laceration and they updated her interventions to include having her bed in the lowest position and a fall mat next to her low bed. The DON reported Resident #1 had no subsequent falls and completed the ordered antibiotic on 01/10/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 9 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0689 Level of Harm - Actual harm A follow up interview on 02/01/24 at 4:10 P.M. with the DON and Assistant Director of Nursing (ADON) reiterated the interventions implemented for Resident #1 following her falls. They verified Resident #1 had been on two-hour checks with toileting assistance provided prior to her falls and there had been no increases or changes to the checks or toileting assistance following the falls. Residents Affected - Few Review of the facility policy titled, Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and to try and minimize complications from falling. Review of the facility policy titled, Fall Prevention Program, revised 10/20/22, revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized risk to minimize the likelihood of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 10 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and a facility catheter care policy, the facility failed to ensure an indwelling urinary catheter was maintained in a manner to prevent infection and care plan interventions were maintained to prevent dislodgement. This affected one (#7) of two residents reviewed for indwelling urinary catheters. The census was 52. Findings include: Review of the medical record revealed Resident #7 admitted to the facility on [DATE] with the diagnoses including, urinary tract infection, sepsis secondary to urinary tract infection, obstructive and reflux uropathy, ureter stent placement, coronary artery disease, coronary artery bypass graph, cerebral vascular accident, hypertension, moderate protein calorie malnutrition, and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was assessed with moderate cognitive impairment, utilized a wheelchair or walker for mobility, required partial to moderate assistance with activities of daily living, substantial to maximum assistance with transfers, and was assessed with an indwelling urinary catheter. Review of a physician order dated 12/18/23 revealed Resident #7 was ordered the placement of an indwelling urinary catheter due to obstructive uropathy. Review of a nursing plan of care dated 09/27/23 revealed a care plan was initiated to address Resident #7's indwelling catheter related to urinary obstruction and infection. Goals of the care plan were noted as the resident will be/remain free from catheter-related trauma. Interventions included to check tubing for kinks as needed and keep the bag lower then bladder level, position the catheter bag and tubing below the level of the bladder and away from entrance room door, provide catheter care routinely and as needed, change as ordered and as needed, and secure catheter to the thigh to decrease trauma and bladder spasms. Observation on 01/29/24 at 9:04 A.M., revealed Resident #7's indwelling catheter bag was on floor of the room under the resident's bed. At 4:39 P.M., Resident #7 was up in a wheelchair at the bedside with the catheter tubing resting on the floor. Observation on 01/30/24 at 10:23 A.M., revealed Resident #7 was seated in the wheelchair with the catheter bag on the floor. At 1:38 P.M. and 2:14 P.M., the catheter bag remained on the floor under the resident's bed. On 01/30/24 at 2:14 P.M. interview with State Tested Nurse Aide (STNA) #456 verified Resident #7's urinary catheter bag was on the floor. STNA #456 confirmed the catheter bag and associated tubing are to remain suspended in a privacy bag and not in contact with the floor. Observation on 01/31/24 at 9:08 A.M. with STNA #460 during indwelling catheter care to Resident #7 noted the associated catheter tubing was unsecured from the Resident #7's thigh. There were no securing mechanism in place to prevent accidental dislodgment of the catheter. Interview with STNA #460 at the time of the observation confirmed the catheter was to be secured to the resident's thigh. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 11 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm On 01/31/24 at 10:15 A.M. interview with the Director of Nursing confirmed catheter tubing was to be secured to the resident's thigh and the catheter drainage bag with tubing was to be stored off the floor. Review of the catheter care policy, revised 05/10/23, revealed privacy bags will be available and catheter drainage bags will be covered at all times while in use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 12 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 a facility policy, the facility failed to ensure resident pain was effectively managed. This affected one (#23) of two residents reviewed for pain management. The facility census was 52. Residents Affected - Few Findings Include: Review of Resident #23's medical record revealed an admission date of 01/18/22. Diagnoses included major depressive disorder, visual hallucinations, dysphagia, dementia, anxiety disorder, osteoarthritis, adjustment disorder, and pseudobulbar affect. Review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #23 was rarely or never understood. A Staff Assessment for Mental Status was completed and Resident #23 was assessed with memory problems. Resident #23 required extensive assistance with bed mobility, transfers, eating, and toilet use. Resident #23 received scheduled and as needed pain medications. Resident #23 displayed facial expressions of pain one to two days during the review period. Resident #23 displayed physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others one to three days during the review period. Resident #23 was on hospice at the time of the review. Review of Resident #23's care plan revised 01/18/24 revealed supports and interventions for the need for monitoring of multiple medical conditions, self-care deficit, impaired cognitive function, and hospice services for terminal diagnosis of dementia for comfort management. Review of an order dated 10/14/22 revealed staff were to document Resident #23's pain level and medicate as needed two times a day for pain rated on a scale of one to ten. If the resident was unable to give a number, the staff were to assess the resident for physical signs of pain. Review of an order dated 03/28/23 revealed Resident #23 was ordered the narcotic pain medication Dilaudid one (1) milligram per milliliter (mg/ml), to give 0.5 ml by mouth every four hours for pain/shortness of breath with scheduled times of 12:00 A.M, 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. Review of an order dated 03/28/23 revealed Resident #23 was also ordered Dilaudid liquid 1 mg/ml, to give 0.5 ml by mouth every hour as needed for pain and dyspnea. The order revealed to give 0.5 mg that equals 0.5 ml, and if three doses were given in 24 hours the staff were to call hospice. Observation on 01/29/24 at 9:38 A.M. of Resident #23 found her calling out with the resident saying, Someone help me. An interview was attempted with Resident #23 and she was found to be confused and not able to be interviewed. Interview on 01/30/24 at 9:14 A.M. with State Tested Nurse Aide (STNA) #471 revealed Resident #23 was cognitively impaired and not able to make her needs known. STNA #471 reported Resident #23 would holler out in pain or if she had a bowel movement and was uncomfortable. STNA #471 reported Resident #23 required total care from staff for all her activities of daily living. Observation on 01/31/24 at 9:43 A.M. of Resident #23 found her yelling and calling out with the resident saying, Help me. Observation on 01/31/24 at 10:02 A.M. of Resident #23 found her still yelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 13 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and calling out from her bed. On 01/31/24 at 10:03 A.M., revealed STNA #471 entered Resident #23's room and STNA #471 was heard reassuring Resident #23 the nurse was coming with her pain medications soon and it will be okay. No other pain management interventions were noted to be attempted. Interview on 01/31/24 at 10:05 A.M. with STNA #471 verified Resident #23 was calling out in pain. STNA #471 stated the nurse was on the other hallway and was running behind with Resident #23's pain medications. STNA #471 reported she repositioned Resident #23 to try and help with her discomfort, but Resident #23 was uncomfortable and the repositioning was not helpful to her. Observation on 01/31/24 at 10:16 A.M. of Resident #23 found she was still calling out in pain and there was no nurse on the hall. Observation on 01/31/24 at 10:25 A.M. revealed Licensed Practical Nurse (LPN) #444 arrived on the hallway and went right to Resident #23's room. Resident #23 continued to call out in pain. LPN #444 reassured Resident #23 she would get her pain medication and her other medications. Interview on 01/31/24 at 10:27 A.M. with LPN #444 verified Resident #23 was calling out and that was how Resident #23 expressed pain. LPN #444 reported Resident #23 was not able verbally express her pain levels and they determined her level by her behaviors. Observation on 01/31/24 at 10:30 A.M. revealed LPN #444 accidentally spilled Resident #23's medications and went to get the Assistant Director of Nursing (ADON) to sign off on the wasted medications and redraw Resident #23's medications. Interview on 01/31/24 at 10:33 A.M. with LPN #444 revealed she spilled Resident #23's antianxiety medication Ativan and Dilaudid, and verified Resident #23 continued calling out in pain. Observation on 01/31/24 at 10:36 A.M. revealed LPN #444 prepared Resident #23 Ativan and Dilaudid again while Resident #23 continued to call out. Observation on 01/31/24 at 10:39 A.M. revealed Resident #23's medications were administered. Interview on 01/31/24 at 10:41 A.M. with LPN #444 verified the medications she administered at 10:40 A.M. were Resident #23's scheduled 8:00 A.M. medications. Review of the facility policy titled, Pain- Clinical Protocol, revised March 2018, revealed the physician would order appropriate medication interventions to address the individual's pain. The staff would use a consistent approach and standardized pain assessment appropriate for the resident's cognitive level. The staff were to provide the elements of a comforting environment and appropriate physical and complementary interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 14 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 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. Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered within ordered time frames. This affected one (#203) of two residents reviewed for medications. The facility census was 52. Findings Include: Review of Resident #203's medical record revealed an admission date of 01/19/24. Diagnoses included multiple fractures of right side ribs, respiratory disorder, protein calorie malnutrition, muscle weakness, chronic obstructive pulmonary disease (COPD), and pleurodynia (pain in upper abdomen or chest when breathing). Review of Resident #203's care plan revised 01/23/24 revealed supports and interventions for risk for pain, risk for decline for activities of daily living, behavior of being verbally aggressive, COPD, and desire to return back home. Review of Resident #203's physician orders revealed Resident #203 had medications ordered for one time a day, two times a day, three times a day, four times a day, at bed time, and as needed (PRN). Further review of the physician orders revealed an order dated 01/20/24 for Resident #203 was receive the aerosol medication ipratropium bromide inhalation solution 0.002 percent (%) to inhale 2.5 milliliters (mL) four times a day related to pleurodynia. Review of Resident #203's corresponding medication administration record (MAR) for January 2024 revealed Resident #203 was to receive her ipratropium bromide 2.5 mLs inhaled four times a day at 7:00 A.M., mid-day, evening, and 7:00 P.M. Interview on 01/29/24 at 10:00 A.M with Resident #203 found her to be alert and aware. Resident #203 reported she was frustrated because she was not getting her morning medications and inhaled medications like she should. Resident #203 reported her morning medications were ordered for 7:00 A.M. which meant the facility had until 8:00 A.M. to administer them. Resident #203 stated it was now 10:00 A.M. and she had not gotten her medications. Resident #203 also stated her inhaled medications were ordered four time a day and she did not get her morning inhaled medication until lunch time, and was not able to get all four treatments the way she should. Resident #203 stated she was not sure all of what she took but she knew she was still waiting on her heart medication and her breathing treatment. Interview on 01/30/24 at 9:11 A.M. with State Tested Nurse Aide (STNA) #471 revealed Resident #203 was cognitively intact and able to make her needs known. STNA #471 reported Resident #203 had complained about the timeliness of her medications and verified she was aware Resident #203 was not getting her medications during the specified timeframes. Interview on 01/31/24 at 8:55 A.M. with Resident #203 revealed she had not gotten medications yet and she should have gotten them by now. Resident #203 stated she wanted her morning inhaled medication at 7:00 A.M. with 8:00 A.M. being the latest it should be given and the rest of her medications medications by 8:00 A.M. Resident #203 stated it was now close to 9:00 A.M. and she had not gotten her morning medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 15 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 01/31/24 at 10:42 A.M. found Licensed Practical Nurse (LPN) #444 was on Resident #203's hallway and was passing medications. Resident #203 was observed asking LPN #444 for her morning medications and LPN #444 responded telling Resident #203 she would get to her but she had two other residents to pass medications to first. Interview on 01/31/24 at 10:50 A.M. with Resident #203 found her sitting in her wheelchair leaning forward with her head in her hands. Resident #203 stated she was frustrated because she had not gotten her morning medications yet and she had wanted them by 8:00 A.M. Resident #203 reported she let the nurse know and she also asked a therapy staff member who stopped by about her medications. Resident #203 reported the therapy staff told her it would be another half an hour or so before the nurse would get to her. Resident #203 stated it was almost time for lunch and her medications were not given to her on time. Observation on 01/31/24 at 10:58 A.M. of LPN #444 found she moved her medication cart outside Resident #203's door and began preparing Resident #203's medications. Interview on 01/31/24 at 11:00 A.M. with LPN #444 verified she was preparing Resident #203's morning medications and that the medications were outside the ordered time frames. Observation on 01/31/24 at 11:10 A.M. revealed Resident #203 was still waiting for her morning medications. At 11:11 A.M., LPN #444 had all of Resident #203's oral medications prepared in a cup and at 11:20 A.M. Resident #203 was provided her morning medications. At 11:28 A.M., LPN #444 provided Resident #203 with her aerosol medication. Review of the facility policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, revealed the purpose of the procedure was to safely administer aerosolized particles of medication into the resident's airway. The facility staff was to obtain a physician order and administer the medication as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 16 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and facility medication administration policy, the facility failed to ensure medications were administered in accordance with physician orders and within prescribed time frames producing a medication error rate greater than five (5) percent (%). This resulted in three medication errors out of 27 opportunities for a medication error rate of 11.11%. This affected one (#154) of three residents observed for medication administration. The facility census was 52. Residents Affected - Few Findings include: Observation on 01/30/24 at 10:38 A.M. revealed Licensed Practical Nurse (LPN) #445 obtained Resident #154's medications from the medication cart and preparing for administration. LPN #445 placed medications including the medication for bone health alendronate sodium oral tablet 70 milligrams (mg) and the diuretic Bumex oral one (1) mg, and proceeded into Resident #154's room administering the medications at 10:48 A.M. Interview with Resident #154 at this time confirmed she had previously consumed breakfast between 8:00 A.M. and 9:00 A.M. Observation at 11:10 A.M. noted LPN #445 was unable to locate Resident #154's aluminum hydroxide 200 mg, magnesium hydroxide 200 mg, and anti-bloating medication Simethicone 20 mg, and proceeded to confirm in interview the medication was not available in the facility. Additional interview at that time with LPN #445, during a review of physician orders, verified Resident #154 was to receive alendronate sodium oral tablet 70 mg at least 30 minutes before the first food or drink of the day, and Bumex 1 mg was scheduled twice daily with the first dose to be administered at approximately 8:00 A.M. Review of Resident #154's physician orders revealed an ordered dated 01/21/24 for aluminum hydroxide 200 mg magnesium hydroxide 200 mg, and Simethicone 20 mg to give 30 milliliters (ml) four times a day for indigestion after meals, and at bedtime with scheduled times 8:00 A.M., between 12:00 P.M. and 1:00 P.M., 5:00 P.M., and between 7:00 P.M. and 10:00 P.M. On 01/22/24, Resident #154 was ordered Bumex oral tablet 1 mg scheduled two times a day for hypertension at 8:00 A.M. and 5:00 P.M. On 01/21/24, Resident #154 was ordered alendronate sodium oral tablet 70 mg, to give one tablet by mouth one time a day every seven (7) days for bone health, and administer with eight (8) ounces of plain water at least 30 minutes before the first food or drink of the day. The resident should be in an upright position and avoid lying down for 30 minutes after administration. The resident was not to eat for at least 30 minutes after administration which was scheduled at 7:30 A.M. On 01/30/24 at 1:10 P.M. interview with the Director of Nursing, during a review of the medical record and facility medication policy, confirmed medications were administered to Resident #154 on 01/30/24 outside of prescribed timeframes. Review of the person-centered medication administration policy, implemented 03/2023, revealed the facility will consult with the pharmacist or prescriber to identify time critical scheduled medications and medications that require special administration times and may not apply to their established by the facility. The facility will communicate the administration times to the resident and allow the resident to select personalized times of administration within time frames established by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 17 of 18 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility to failed to ensure medications were stored in a safe and secure manner. This affected one (#5) of one residents observed for medication storage. The census was 52. Findings included: Review of the medical record for Resident #5 revealed an admission date of 01/23/21 with diagnoses which included diabetes mellitus, anxiety disorder, and insomnia. Review of the physician orders for Resident #5 revealed an order for the antianxiety medication Klonopin 0.5 milligrams (mg) to take one tablet by mouth twice daily, the pain medication gabapentin capsule 100 mg to give one capsule by mouth twice daily, and the sleep aid melatonin three (3) mg by mouth at bedtime for insomnia. Review of the medication administration record (MAR) for January 2024 revealed Resident #5 received Klonopin, gabapentin, and melatonin at bedtime on 01/29/24 which were signed as given by Licensed Practical Nurse (LPN) #479. Interview with Resident #5 on 01/30/24 at 8:15 A.M. verified there were medications left on the counter in her room in a cup, and stated she did not know if the facility gave her the bedtime medications. Observation on 01/30/24 at 8:18 A.M, revealed three pills, one capsule and two tablets, in a pill cup with Resident #5's name written on it in the resident's room. Interview with LPN #445 on 01/30/23 at 8:26 A.M. verified she had not been in Resident #5's room because she started her medication pass on the B-hall. LPN #445 was not aware where the medications came from in Resident #5's room. Interview with Director of Nursing (DON) on 01/30/24 at 10:38 A.M. verified there were three medications left in Resident #5's room on her counter. The DON stated the three medications were the resident's bedtime medications which included Klonopin, gabapentin and melatonin. Review of the facility policy titled, Storage of Medications, dated 11/20, revealed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366312 If continuation sheet Page 18 of 18