Health inspection·January 11, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of medical records, resident and staff interviews, the facility failed to ensure residents were included in their care plan meetings. This affected two (#17 and #95) of 40 sampled residents. The facility census was 186. Findings include: 1. Review of Resident #17's medical record identified admission to the facility occurred on 05/24/19. Diagnoses included major depression, diabetes, obesity and anxiety. The records identified Resident #17 with intact cognition. Review of care meeting notes dated 07/27/23 at 11:54 A.M. identified no participation including Resident #17 in his care plan choices. Review of Resident #17's most recent care meeting notes dated 11/09/23 at 12:15 P.M. identified the meeting was held on a phone conference; however, the conference did not include the resident. Interview with Resident #17 on 01/08/24 at 11:51 A.M. revealed he has not attended any care plan meetings, but would like to. Interview with Licensed Social Worker (LSW) #700 on 01/11/24 at 10:04 A.M. revealed residents were not being invited to their care meetings because I share an office with another LSW. LSW #700 confirmed she never thought about going to Resident #17's private room to do the meeting. 2. Review of Resident #95's medical record identified admission to the facility occurred on 01/22/19. Diagnoses included dementia, diabetes, high blood pressure and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #95 had moderately impaired cognition. Review of Resident #95's social services notes dated 10/25/23 at 11:48 A.M. identified his care conference was held. The notes identified Resident #95 was out of the building attending a facility activity at the time the meeting was held. Review of social services notes dated 07/26/23 at 11:29 A.M. identified a care meeting was held and Resident #95 was out of the facility at a baseball game. Interview on 01/08/24 at 10:40 A.M., Resident #95 stated he has not participated in any meetings about his care and would like to. Interview with LSW #560 on 01/10/24 at 1:49 P.M. confirmed the facility has not been working to ensure care meetings are being held at a time convenient for residents and they were not working around planned activities. The interview confirmed Resident #95 has not been able to participate in his last two meetings because they were scheduled when he was on facility initiated activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 2 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to ensure residents receive proper treatment and assistive devices to maintain their hearing abilities. This affected one (#79) of one resident identified with hearing issues. The facility census was 186. Residents Affected - Few Findings include: Review of Resident #79's medical records revealed he was admitted on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment and hearing difficulties. Observation on 01/10/24 at 9:48 A.M. revealed Therapeutic Program Worker (TPW) #460 pushing Resident #79 in a wheelchair. TPW #460 was leaning close towards his ear saying Can you hear me? Resident #79 did not respond. During an interview with Resident #79 on 01/08/24 at 11:46 A.M., Resident #79 was observed at that time with no hearing aides and his television was very loud. Resident #79 stated he has a hard time hearing sometimes and he doesn't have any hearing aides. Interview with Licensed Practical Nurse (LPN) #418 on 01/10/24 at 8:21 A.M. identified she has never known Resident #79 not to be able to hear that well. LPN #418 confirmed Resident #79 has had no audiology exams since his admission oo 06/06/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 3 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, resident interview, staff interview, and policy review, the facility failed to ensure safe smoking. This affected two residents (#43 and #171) of two residents reviewed for smoking. The facility census was 186. Findings include: 1. Review of the medical record for Resident #171 revealed an admission date of 11/03/22. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic respiratory failure with hypercapnia. Review of the Minimum Data Set (MDS) assessment, dated 11/03/23, revealed Resident #171 had cognition impairment. Review of the MDS assessment revealed Resident #171 utilized oxygen. Review of the care plan, dated 11/16/23, revealed Resident #171 was a smoker and smoked unsupervised. Interventions included following smoking policy and procedure, smoking only in designated areas, storing cigarettes and lighter in medication room, and may keep one or two cigarettes on his person. Further review of the care plan revealed Resident #171 had a history of chronic respiratory failure with hypoxia and hypercapnia with interventions in place to apply two liters of oxygen via nasal cannula when going to bed and remove in the morning. Review of the physician orders dated 12/30/22 revealed Resident #171 had an order in place for two liters oxygen via nasal cannula every evening and night shift when resident goes to bed and remove in the morning. Review of the physician orders dated 07/18/23 revealed Resident #171 had an order in place to be an unsupervised smoker, have cigarettes and lighter stored in medication room, and may have one or two cigarettes at a time. Review of the quarterly Smoking Safety Evaluation dated 10/29/23 revealed Resident #171 was a smoker and did not require supervision. Observation and interview on 01/08/24 at 10:34 A.M. revealed Resident #171 was a smoker and went to the designated smoking area multiple times a day. Resident #171 revealed he kept his smoking paraphernalia in his pockets. Observation revealed multiple cigarettes and a lighter located in his coat pocket. An oxygen concentrator was located adjacent to the bed. Interview on 01/08/24 at 12:14 P.M. with Licensed Practical Nurse (LPN) #424 revealed cigarettes and lighter were to be kept locked in the medication room per the smoking policy. LPN #424 revealed Resident #171 kept his lighter on him and asked for two cigarettes at a time when going to smoke. LPN #424 revealed Resident #171 had a history of being caught smoking in his room and he utilized oxygen. Interview on 01/10/24 at 9:06 A.M. with LPN #422 revealed Resident #171 utilized oxygen only at night. He was an independent smoker but his cigarettes and lighter were locked in the medication room. Observation on 01/10/24 at 10:04 A.M. revealed Resident #171 exited his room and exited the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 4 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 - Few facility to the designated smoking area without stopping at the nursing station. Resident #171 was observed retrieving his cigarette and lighter from his coat pocket, lit the cigarette, and started smoking. Observation and interview on 01/10/24 at 10:15 A.M. with LPN #422 revealed Resident #171 entered the facility placing cigarettes and lighter in his pocket and returned to his room. LPN #422 confirmed Resident #171 had a smoke break without retrieving any cigarettes and lighter from her or the medication room. LPN #422 also verified he kept his cigarettes and lighter on his person after entering the building. 2. Review of the medical record for Resident #43 revealed an admission date of 07/13/18. Diagnoses included chronic obstructive pulmonary disease (COPD), bilateral age-related cataracts, and nicotine dependence. Review of the MDS quarterly assessment, dated 12/22/23, revealed Resident #43 had intact cognition. Review of a physician's order, dated 04/21/23, identified Resident #43 as an independent, unsupervised smoker with use of a protective smoke apron. Review of Resident #43's care plan, revised 07/08/23, revealed Resident #43 was able to smoke independently and unsupervised with the use of a smoke apron. Review of Resident #43's Smoking Safety Evaluation, dated 12/16/23, revealed Resident #43 had no burns to his skin or clothing and did not drop ashes on himself. Observation on 01/09/24 at 10:12 A.M. revealed Resident #43 seated in his motorized wheelchair. Cigarette ashes were noted on his lap. He had his smoking supplies, a pack of cigarettes and a lighter, in the left breast pocket of his jacket. There were multiple circular burns observed in his clothing. Observation on 01/10/24 at 9:27 A.M. revealed Resident #43 mobilized himself in his motorized wheelchair down the elevator and out the main entrance to the designated smoking area. He did not have on a smoke apron. Resident #43 retrieved his smoking supplies out of his left breast pocket and proceeded to smoke. Interview on 01/10/24 at 9:35 A.M. with Housekeeper #351, stationed near the main entrance, verified Resident #43 was not wearing a smoke apron. Housekeeper #351 stated he never wore a smoke apron. Observation and interview on 01/10/24 at 9:53 A.M. with Resident #43 revealed he mobilized himself back up to the nursing unit. Resident #43 was observed with ashes on his lap and no smoke apron on. Resident #43 verified he never wore a smoke apron when he went outside to smoke. Resident #43 stated the smoke apron was overkill and he did not need it, nor did he wear it. Resident #43 stated he only dropped a few ashes here and there. Interview on 01/10/24 at 9:57 A.M. with Therapeutic Program Worker (TPW) #461 verified Resident #43 had ashes on his lap. TPW #461 stated she believed he had a smoking apron but he did not routinely wear it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 5 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 - Few Interview on 01/10/24 at 9:53 A.M. with LPN #407 revealed Resident #43 had a smoke apron in his room but refused to wear it. LPN #407 stated the staff occasionally reminded him to wear it. LPN #407 verified he was still able to go out to smoke independently whether he wore the smoke apron or not. Interview on 01/11/24 at 9:19 A.M. with Registered Nurse Clinical Care Coordinator (RNCCC) #433 verified Resident #43 had holes in his clothing from cigarette burns but believed them to be old holes. RNCCC #433 stated his family recently sent him new clothing and the staff are monitoring the new clothing for new holes. RNCCC #433 verified Resident #43's care plan and physician's orders identified the need for a smoke apron while out smoking independently but he did not consistently wear it. Review of the facility policy titled Smoking, dated 04/26/23, revealed all residents who smoke will be assessed to determine if the resident is safe to smoke unsupervised. Any resident deemed safe to smoke using the assessment form will be allowed to smoke in designated smoking areas, at designated times, and in accordance with their care plan with supervision as per facility policy. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers responsible for supervising residents while smoking. If a resident does not abide by the policy or their care plan, including refusal to wear protective gear, the resident's care plan may be revised to include additional measures such as prohibited smoking or even discharge. The interdisciplinary team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by developing a safe smoking plan. Documentation to support decision making will be included in the medical record, including resident's wishes, assessment of relevant functional and cognitive factors affecting ability to smoke safely, response to smoking cessation intervention and compliance with the smoking policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 6 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 observations, medical record review, review of facility policy, and resident and staff interviews, the facility failed to provide adequate pain management which resulted in actual harm to Resident #111 who continued to have uncontrolled pain at a level of 8 out of 10 (with 10 being the highest level). This affected one (#111) of two residents reviewed for pain management. The facility census was 186. Residents Affected - Few Findings include: Review of Resident #111's medical record revealed an admission date of 08/22/23. Diagnoses included chronic pain, chronic obstructive pulmonary disease (COPD), anxiety, depression, and mental and behavioral disorders. Review of Resident #111's quarterly pain assessment, dated 11/16/23, revealed pain over the last five days making it hard to sleep at night, which is frequently limiting his day to day activities. Resident has indicated his pain was moderate and rated as an eight out of 10. The care planning interventions included for the physician to check mark which interventions to utilize in helping the resident's pain revealed no pain interventions were checked and were left blank. Review of Resident #111's Medication Administration Record (MAR) for January 2024 revealed an order for ibuprofen 200 milligrams (mg) twice a day for pain. Nothing was ordered for pain to be given as needed (PRN). Review of the Physician-Patient Encounter Note dated 11/29/2023 revealed the resident was assessed by Physician #553 for an evaluation. Review of the physician's encounter note revealed question number nine on this form asked for the resident's most recent pain level, pain scale and date. All those questions were left blank. The note revealed the resident complained of new onset left hand pain. He reported the pain had been going on for a couple weeks. The pain was more severe in his third digit at the metacarpophalangeal (MCP) joint. The resident also complained of bilateral knee pain. The resident was offered a topical treatment and an occupational therapy evaluation, which he refused. The note revealed to continue current treatment with no changes in medications. Observation of Resident #111 on 01/08/24 at 11:26 A.M. revealed resident sitting in his recliner chair appearing irritated and anxious. Interview on 01/08/24 at 11:26 A.M. with Resident #111 revealed he was angry as he has been in frequent and uncontrolled pain since he admitted and the facility staff have done nothing to address it. He further stated he has notified multiple staff, including Physician #553. Upon his admission Physician #553 decreased his ibuprofen and this dosage is ineffective in relieving his pain. Resident #111 stated he wants his ibuprofen dosage back to what he was originally taking before coming to this facility, which consisted of ibuprofen 400 mg three times a day. Resident #111 stated he was currently receiving ibuprofen 200 mg twice a day and he has been in pain since the dosage decrease. He further stated Physician #553, along with all the other facility staff, were aware of how he has been feeling regarding his pain and they are well aware of how he feels about the decrease in this pain medication. He stated he has been offered Tylenol and has told the nursing staff, along with Physician #553, that Tylenol upsets his stomach and he cannot take it. Interview on 01/10/24 at 1:00 P.M. with Registered Nurse (RN) #436 confirmed Resident #111's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 7 of 8 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 366325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Veterans Home 3416 Columbus Ave Sandusky, OH 44870 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 quarterly pain assessment dated [DATE] was accurate. RN #436 confirmed the resident was not receiving any PRN pain medications. Interview with Licensed Practical Nurse (LPN) #396 on 01/10/24 at 08:40 A.M. revealed the medical team has discussed with Resident #111 other options. The medical team reviewed his labs and only wanted to put him on one ibuprofen due to his labs indicating there was a decline in his kidney function. Resident #111 wants his medications given his way and not the way the physician has ordered. LPN #396 stated Resident #111 currently has an order for ibuprofen 200 mg to be given in the morning and at bedtime. LPN #396 stated this is the only pain medication Resident #111 can have at this time. Interview on 01/10/24 at 11:11 A.M., LPN #396 stated she called Physician #553 and notified her Resident #111 wanted to be seen today regarding his pain and to increase his ibuprofen. LPN #396 stated Physician #553 said Resident #111's pain was all well documented regarding his ibuprofen order and complaints of his pain. Physician #553 stated she would try to see Resident #111 today, but if she was not able to see Resident #111 today, she would see him when she became available. Additional review of the medical record revealed a progress note dated 01/10/2024 revealed Nurse Practitioner (NP) #551 was asked to see this resident for multiple complaints. Resident #111's first complaint was pain in his hands and knees which he rated as a six out of 10 on the pain scale, stating this pain was an ache. The resident stated that he was diagnosed with arthritis and had been taking ibuprofen 400 mg three times a day, which provided relief. Resident #111 stated he was upset that when he was admitted into this this facility, the ibuprofen was decreased to 200 mg twice a day. Further review of this note reveals he did not want any arthritis cream or muscle rub, no K-Pad, or any acetaminophen. Resident #111 was adamant he had tried all of these things in the past and they were ineffective. Resident #111 insisted the ibuprofen at 400 mg three times a day was all that would work. He had been taking it that way for over twenty years without any problems and it reduced his pain down to a two or three, which was tolerable. Resident #111 stated to NP #551 he was left-handed and opening and doing things etc., was difficult for him. NP #551 thanked the resident for his time, and stated the ibuprofen would be looked at. NP #551 documented after evaluating Resident #111's laboratory (lab) results for his basic metabolic panel from December 2023, as well as his lab results for his comprehensive metabolic panel from August 2023, his kidney function was good on those two occasions. NP #551 increased the ibuprofen to 400 mg three times a day. Review of the January 2024 MAR revealed ibuprofen 400 mg three times a day was ordered on 01/10/24. Review of the facility policy titled Pain Management Work Instructions,dated 05/13/08, revealed a pain assessment and treatment program is used to evaluate the resident's pain consistently and accurately. For 4-6 (moderate pain) give Tylenol 650 mg and reassess. If unrelieved in one hour but minimized, attempt diversional activities. If pain persists beyond 48 hours and/or the condition worsens, notify physician for standing orders. Further review of this policy reveals if the pain is a 7-10 (severe pain) give Tylenol 650 mg per standing order or specific ordered pain medication for severe pain. Reassess and if unrelieved notify physician. The policy further reveals the process of treating acute or chronic unrelieved pain is to notify the physician with consideration of a referral to neurologist, pain clinic, or other. Unit Supervisor to evaluate use of PRN pain medication and refer to physician if needed when the PRN medication is used routinely. For moderate to severe pain that occurs every day, formulate a pain management program with specific interventions that address the resident's individual needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366325 If continuation sheet Page 8 of 8