Health inspection·November 6, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wheelchair by LPN #602 placing the resident at risk for serious life-threatening harm, injuries, and/or negative health outcomes. Additionally, the facility failed to protect the resident from further abuse and failed to immediately report resident abuse to the administrator placing 26 additional residents who resided on the Memory Care Unit at risk for abuse. On 09/16/25 beginning at approximately 7:50 P.M., CNA #400 witnessed LPN #602 aggressively pushing Resident #241 out of his room and swearing at the resident while the resident was trying to stop the wheelchair by reaching out his arms, placing his feet on the ground and yelling no. LPN #602 then continued to push Resident #241 toward the nurses' station where LPN #602 hit the resident's arm and pulled on the back of the resident's shirt to keep the resident in the wheelchair. LPN #602 then aggressively pushed Resident #241 in his wheelchair into a recliner causing the resident to fly forward hitting the recliner and then landing on the floor. While Resident #241 was on the floor, LPN #602 tried to pick the resident up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 sat in the resident's wheelchair next to the resident on the floor and later kicked the back of the resident's right leg. CNA #400 failed to intervene to protect the resident and failed to call for additional help. LPN #614 arrived on the unit and LPN #602 reported the resident had fallen. RN Supervisor #700 then arrived on the unit to assess Resident #241 all while LPN #602 remained working on the Memory Care Unit until CNA #400 reported the abuse to RN Supervisor #700 at approximately 9:15 P.M. This resulted in serious psychosocial harm as Resident #241 was agitated and upset attempting to get away from LPN #602. Resident #241 also sustained three skin tears to the bilateral upper extremities. Furthermore, all residents on the Memory Care unit were placed at potential risk for serious injury and/or harm when LPN #602 continued to work on the unit 9:15 P.M. Although the Immediate Jeopardy was removed on 09/19/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficient practice was corrected on 09/25/25 when the facility implemented the following corrective actions: On 09/16/25 at 9:15 P.M., CNA #400 reported an allegation of abuse against LPN #602 to RN Supervisor #700. On 09/16/25 at 9:16 P.M., off duty RN Supervisor #772 called to report the allegation of abuse to the police department. On 09/16/25 at 9:18 P.M., RN Supervisor #700 removed LPN #602 from the floor to the nursing supervisor's office on the first floor. On 09/16/25 at 9:22 P.M., Assistant Director of Nursing (ADON) #549 notified the Administrator of the allegation of abuse. On 09/16/25 at 9:23 P.M., ADON #549 notified the DON of the allegation of abuse. On 09/16/25 at 9:28 P.M., RN Supervisor #700 began getting statements from the nursing staff on duty at the time of the allegation of abuse. On 09/16/25 at 9:29 P.M., RN #740 and LPN #614 began head-to-toe assessments of the residents on the unit. On 09/16/25 at 9:29 P.M., RN Supervisor #700 and RN #748 began education of the facility Abuse policy with nursing staff. Education was completed on 09/18/25. On 09/16/25 at 9:29 P.M., Police Officer #541 reported to the Nursing Supervisor's office to interview LPN #602 and CNA #400. On 09/16/25 at 10:09 P.M., the DON notified RN Supervisor #700 to inform LPN #602 he was on administrative leave effective immediately. LPN #602 was also informed to report on 9/17/25 at 3:00 P.M. to the Police Department for questioning and interviewing. On 09/16/25 at 11:45 P.M., RN #740 completed a head-to-toe assessment for Resident #241 with no new findings since previous assessment at 7:55 P.M. On 09/17/25 at 12:28 A.M., RN #740 emailed a request for psychiatric services to evaluate Resident #241. On 09/17/25 at 6:00 A.M., ADON #549 reported for duty and started the Resident Safety interviews of the residents on the unit. On 09/17/25 at 6:00 A.M., LPN #901 and LPN #637 completed head-to-toe assessments of residents on the unit who refused the night before. On 09/17/25 at 6:00 A.M., RN Supervisor #780 and RN Supervisor #588 continued nursing staff education on the facility's Abuse policy with first shift (continued on next page) 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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nursing staff. On 09/17/25 at 7:52 A.M., ADON #549 notified Resident #241's guardian of the allegation of abuse. On 09/17/25 at 8:37 A.M., ADON #549 notified Nurse Practitioner (NP) #439 of the allegation of abuse for Resident #241. On 09/17/25 at 9:00 A.M., the Administrator and the DON reviewed the video of the allegation of abuse with Lieutenant #457. On 09/17/25 at 11:12 A.M., psychiatric services responded to an email indicating they would evaluate Resident #241 on 09/17/25; however, the evaluation was rescheduled as Resident #241 was in the emergency room for evaluation of hematuria and urinary retention. On 09/17/25 at 11:17 A.M., ADON #634 sent the facility Abuse policy to the staffing agencies for staff re-education. On 09/17/25 at 3:00 P.M., LPN #602 reported to the police department and was interviewed by Lieutenant #457. On 09/17/25 at 3:15 P.M., the Administrator, ADON #549 and the DON interviewed LPN #602. At the conclusion of this interview, LPN #602 was arrested by Lieutenant #457 and transported to the county jail and was booked on charges of assault and abuse. On 09/18/25, Licensed Social Worker (LSW) #473 completed a Brief Interview for Mental Status (BIMS) for Resident #241. Resident #241's BIMS score was six out 15 indicating severe cognitive impairment. On 09/18/25, resident safety monitoring was put into place. The DON or designee would conduct random monitoring of five random residents with a (BIMS) of 8 or above two times a week for four weeks, then one time a week for four weeks. Skin assessments are done weekly on all residents on the unit on one of the resident's shower days (including those with a BIMS below 8) by the LPN assigned to the unit. Findings of the monitoring and skin assessments will be discussed with the Quality Assurance and Performance Improvement (QAPI) Committee to determine if further monitoring will be required. Subsequent document review revealed resident weekly skin assessments were completed 09/16/25 through 10/09/25. Resident Safety Monitoring was completed for five residents on 09/18/25, 09/19/25, 09/22/25, 09/24/25, 09/26/25, 09/29/25, 10/01/25, 10/03/25, 10/07/25, and 10/09/25. On 09/18/25, education for all staff was put into place on the Relias (electronic education platform) system. Topic was de-escalation techniques and verbal de-escalation strategies. This education was completed by 09/25/25. On 09/19/25 at 9:00 A.M., the QAPI Committee (Superintendent #990, Administrator, DON, Social Services #433, ADON #464, ADON #634, Infection Preventionist #671, Chief Compliance Officer #994, Police Chief #409, Lieutenant #457, Medical Director #688, Pharmacy Staff #453, Activities Staff #570, Support Services #632, ADON #721, MDSRN #472, and Rehabilitation Staff #995 met via TEAMS to discuss this allegation of abuse and the mitigation items put into place. On 09/19/25 at 4:30 P.M., psychiatric services evaluated Resident #241 with no new recommendations. On 10/01/25 at 9:30 A.M., the Administrator attended the Resident Council meeting and educated the residents who attended on the facility Abuse and Reporting policy. On 10/15/25 and 10/16/25, interviews with 15 staff (RN #700, LPN #614, LPN #960, LPN #911, LPN #901, LPN #637, CNA #400, CNA #293, CNA #770, CNA #663, CNA #296, CNA #292, CNA #725, CNA #714, and CNA #684) verified recent training on the abuse policy and on de-escalation strategies with appropriate knowledge. Review of the medical record for Resident #241 revealed an admission date of 06/10/24. Diagnoses included Alzheimer's disease, dementia, hypertension, bilateral primary osteoarthritis of the knee, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was frequently incontinent of bowel and bladder. The resident required substantial/maximal assistance with toileting and partial/moderate assistance with transfers. Review of Resident #241's plan of care for non-compliant behaviors initiated 10/09/24 and last revised 03/21/25 revealed the resident had the potential to be non-compliant with refusing his medications, treatments, and peri-care at times. Interventions included acknowledging the resident's right to refuse or choose against recommended treatment. Staff should offer education and reassurance to resident as needed. Staff would (continued on next page) 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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few review non-compliance with the physician and other members of the Interdisciplinary Team (IDT) as needed. Further review of the care plan revealed the resident had anxiety at times. Interventions included attempting to find cause of anxiety, encouraging resident to voice needs and allowing resident time to do so and attempting to divert attention. Also, to maintain a calm manner while interacting with the resident and reduce sensory stimulation by maintaining a quiet environment. Staff were to monitor behaviors and notify the registered nurse and social worker as needed. Review of the resident's communication plan of care revealed the resident had difficulty finding words or finishing thoughts at times related to Alzheimer's disease. Interventions included explaining all procedures prior to beginning them, giving the resident simple one to two step commands while providing instructions. Also, for staff to monitor for non-verbal forms of communication such as smiling, facial grimaces, agitation, guarding, and pointing. Staff were to gain attention and eye contact before speaking to resident and ask simple questions that require yes or no answers, allowing time for response. Repeat or rephrase questions as needed to assure resident's understanding. Continued review of the care plan revealed the resident required placement in the Memory Care Unit due to cognitive impairment and dementia diagnoses and the resident could be resistive to care. Interventions included when the resident was upset, it would be helpful for him to feel better when someone listened to his concerns. Additionally, staff could show care/respect by being nice/friendly. Review of a skin observation report dated 09/15/25 revealed Resident #241 had bruising to the front right thigh, a scar to the front left lower leg, bruising to the left forearm, and skin tear to the right forearm measuring 3.8 centimeters (cm) in length by 0.3 centimeters in width. Review of video surveillance footage dated 09/16/25 beginning at approximately 7:50 P.M., revealed LPN #602 entered Resident #241's room. LPN #602 remained in the room for approximately 20 seconds then LPN #602 aggressively wheeled Resident #241 out of his room while the resident was attempting to stop the wheelchair by putting his feet down and grabbing the door. CNA #400 could be seen walking toward Resident #241 and LPN #602 as the incident occurred. LPN #602 continued to wheel the resident up to the nurse's station. LPN #602 can be seen hitting the resident's right arm and grabbing and pulling the back of the resident's shirt as he was attempting to move away from the nurse while the nurse continued to hold the wheelchair in place. LPN #602 can be seen moving his mouth and pointing and appeared to be speaking to the resident. Approximately a minute later, CNA #400 approached LPN #602 at the nurse's station while carrying a white packet which LPN #602 opened and handed back to her. CNA #400 then returned to the hallway. Resident #241 appeared agitated and in distress. Approximately 30 seconds later, LPN #602 then aggressively pushed Resident #241 in his wheelchair forcefully and directly slamming the resident's legs into the front of the recliner causing the resident to fly forward hitting the recliner then landing on the floor with CNA #400 present and witnessing the incident. LPN #602 attempted to pick Resident #241 up by the back of his pants. Resident #241 then rolled onto his buttocks. LPN #602 remained standing over the resident while he was on the floor. LPN #602 glanced at the camera several times then removed his name badge. Less than a minute after slamming the resident into the recliner, LPN #602 moved the resident's wheelchair back and then sat in the resident's wheelchair next to the resident on the floor. Approximately 25 seconds after sitting in the resident's chair as LPN #614 was walking down the hall looking toward the resident on the floor, LPN #602 lifted his left leg and kicked the back of the resident's lower right leg as LPN #614 arrived at her medication cart near the nurse's station. LPN #614 remained at the medication cart for over a minute looking at her computer screen while CNA #400 approached Resident #241 and LPN #602 as LPN #602 appeared to be speaking. CNA #400 stood there for one minute before leaving toward the hallway behind the nurse's station. LPN #614 was then (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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few seen at the desk using the phone about five minutes after the incident began. CNA #400 returned to the resident's hallway and continued cleaning up water from the floor in the hallway. CNA #400 was not seen intervening between the resident and the nurse to protect the resident and CNA #400 was not seen attempting to call for additional help. As LPN #614 was on the phone, about one minute later RN Supervisor #700 arrived on the unit and then began addressing Resident #241. Continued review of the video surveillance revealed on 09/16/25 at 8:09 P.M. and 8:13 P.M., LPN #602 was seen continuing to work on the unit. Review of an incident report dated effective 09/16/25 at 7:55 P.M. revealed RN Supervisor #700 received a statement of alleged physical and verbal abuse from CNA #400 towards Resident #241. Resident #241 was unable to give a description. ADON #549 was notified, the staff member was removed from the floor immediately, and the resident was assessed. Psychiatric services and social services were notified. No injuries observed at the time of the incident. The physician was notified on 09/17/25 at 8:37 A.M. and the resident's guardian notified on 09/17/25 at 7:52 A.M. Review of a late entry nurses note by RN #740 effective for 9/16/25 at 7:55 P.M. with the document created on 09/16/25 at 11:14 P.M revealed a skin assessment had been completed for Resident #241 and three skin tears were added to the skin editor. Review of a nurses note by LPN #614 dated effective for 9/16/25 at 7:58 P.M. with the documentation not created until 09/16/25 at 9:08 P.M., revealed Resident #241 stated he needed to go the bathroom. CNA #400 attempted to assist the resident who then refused care while cussing and yelling at the CNA. When leaving the room, Resident #241 then attempted to enter another resident's room causing that resident to yell at Resident #241. Resident #241 yelled this is my room. Resident #241 was redirected to his room with his name on it and the resident then stated, I know they invited me over there. Resident #241 then wheeled himself to the sink and started to brush his teeth. Review of a nurses note by LPN #614 with an effective date of 9/16/25 at 8:09 P.M. with the document not created until 09/16/25 at 9:21 P.M., revealed a nursing assistant observed water throughout the hallway and a few resident rooms with water on floors. The nurse noted Resident #241 was observed coming out of his bathroom from his room with a urinal he had just filled from the hopper on the back of the toilet. Resident #241 was then observed raising the urinal and throwing water all over the hallway floors and his room floor. Review of a nurses note dated 9/16/25 at 8:32 P.M., LPN #602 documented assisting Resident #241 to a stationary chair in the common area. Resident #241 attempted to stand up from the wheelchair and landed on the floor on his knees. Resident noted clothed and wearing shoes in good condition. Resident denied pain. The floor was dry and free of debris. Range of motion times four and resident assessed. LPN #602 noted no injuries to the resident's knees. Staff assisted resident to the stationary chair. Interventions included a bladder scan and toileting assistance. LPN #602 initiated an incident report on 09/16/25 at 8:00 P.M. noting the resident had no injuries. LPN #602 notified the guardian on 09/16/25 at 8:12 P.M. and the physician at 8:32 P.M. Review of a facility Self-Reported Incident (SRI) dated 09/16/25 at 9:47 P.M. and review of the subsequent investigation reports revealed on 09/16/25 at approximately 9:15 P.M., the facility became aware of an allegation of staff to resident abuse on the Memory Care Unit. The facility noted the incident affected the resident causing agitation. The police were notified on 09/16/25 at 9:20 P.M. Resident #241 sustained skin injuries from fall occurring during the incident. The resident representative was notified on 09/17/25 at 7:52 A.M. Resident #241 was unable to provide useful information. Further review of the SRI investigation revealed CNA #400 informed the facility that LPN #602 was pushing Resident #241 in his wheelchair and yelling at the resident. The resident's knees struck the front of the recliner, causing him to fall forward out of the wheelchair and onto the floor because of LPN #602 pushing the resident aggressively in the wheelchair and during transfer the (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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident fell onto the floor. LPN #602 admitted to using inappropriate language while assisting the resident and spoke loudly due to the resident being hard of hearing. LPN #602 admitted to using excessive force when transferring the resident into the recliner by grabbing the resident's waistband and shorts. A head-to-toe assessment of Resident #241 was completed by RN #740 revealing skin injuries including an abrasion. During RN #740's assessment the resident had stated the nurse had hit him. Further review of the facility SRI investigation revealed the resident had one skin tear to the left upper arm, one skin tear to the left upper forearm, and one skin tear to the left upper arm above elbow and it was unknown if the injuries were caused by LPN #602. The resident displayed expressions of anger while in the presence of LPN #602. Review of a description of the incident revealed LPN #602 was removed from the resident care area and escorted out of the facility. Further review of the follow-up SRI investigation report noted upon further review and confirmation by video surveillance, LPN #602 was arrested by the police department and transported to the county jail awaiting further court proceedings at this time related to pending charges of patient abuse and assault. The facility completed skin sweeps for all residents on the Memory Care Unit and requested a psychiatric evaluation for the resident. Review of the SRI facility conclusion revealed the allegation of abuse was substantiated and verified by evidence. Review of CNA #400's statement dated 09/16/25 at 9:15 P.M. revealed Resident #241 was filling the urinal with water and throwing water around the floor. CNA #400 revealed when she noticed the water she grabbed a spill kit/mop to attempt to get the water up per the nurse request. When returning, LPN #602 was pushing Resident #241 through the door very aggressively while calling the resident expletive names (vulgar or profane words used to express strong emotion). CNA #400 revealed she tried to take over and get Resident #241 to the common area, but LPN #602 kept pushing him in the wheelchair very aggressively while yelling at the resident. CNA #400 noted she believed the resident was not in his right mind, his sentences were not making sense, and he was scared. CNA #400 revealed when LPN #602 got the resident to the recliner in the common area he slammed his knees in the chair and body, and the resident fell. CNA #400 revealed LPN #602 had not carefully transferred the resident like we were instructed to do. CNA #400 revealed during report she was told Resident #241 was a stand lift, so when she saw how LPN #602 manhandled him, she was very scared. CNA #400 revealed she walked over to try and help get the resident up, but LPN #602 told her to keep cleaning the spill. CNA #400 revealed she had not wanted to leave Resident #241 as she was scared for him. CNA #400 revealed he had two bloody sores on his right and left arm. CNA #400 stated Resident #241 was stating how he thought LPN #602 was his friend and CNA #400 revealed that just broke my heart. CNA #400 revealed yes the resident was throwing water, but she had removed the urinal, it did not have to go that way. CNA #400 revealed LPN #602 stated Resident #241 climbed out of the chair to the other nursing assistant which was not true. Further review of CNA #400's interview dated and initialed 09/16/25 revealed CNA #400 indicated she had been educated on the abuse policy, had worked on the Memory Care Unit on 09/16/25 on second shift, had witnessed Resident #241 throw water on the floor, and had witnessed staff use inappropriate language and excessive force while assisting Resident #241. CNA #400 also documented when assisting Resident #241 to bed, the resident stated, that nurse hit me. Review of staff statements for four additional staff (LPN #614, CNA #997, CNA #998, and CNA #999) working on the unit at the time of the alleged abuse revealed the four employees were not present in the common area during the incident and had not witnessed the fall or abusive mistreatment of the resident. Review of LPN #602's employee timecard dated 09/16/25 revealed the nurse began their work shift at 2:43 P.M. and then punched out at 10:16 P.M. after being placed on administrative leave. Review of a nurses note by LPN #614 effective for 09/16/25 at 10:59 P.M. with the (continued on next page) 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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few documentation not created until 09/16/25 at 11:43 P.M. revealed LPN #614 had observed Resident #241 coming out of the bathroom from his room in his wheelchair holding a urinal filled with water that was filled using the hopper from the toilet. The resident was asked what he was doing when he raised the urinal and started to throw water on the floor in the hallways and his room. LPN #614 documented the resident had three skin tears with skin flaps observed. One to the right upper arm measuring one centimeter (cm) in length by one cm in width; a second skin tear to the left back of upper arm measuring three cm in length by five cm in width; and a third skin tear to the left lower arm measuring two cm in length by three cm in width. The resident denied pain or discomfort with range of motion within normal limits to the bilateral upper extremities. LPN #614 noted the skin tears were cleansed with normal saline and a dressing was applied to all three skin tears with skin flap. A new intervention was initiated for padding for the pole behind the toilet. Review of a late entry nurses note by RN #740 effective for 09/16/25 at 11:45 P.M. with the documentation created on 09/18/25 at 11:16 A.M. revealed Resident #241 had a head-to-toe skin assessment completed with no new findings since previous assessment at 7:55 P.M. Review of a police report dated 09/16/25 through 09/24/25 revealed after reviewing witness statements and video surveillance there was overwhelming evidence beyond a reasonable doubt that LPN #602's actions warranted criminal charges. On 09/17/25, LPN #602 was charged with assault and patient abuse and taken to the county jail. On 09/24/25 the police department was notified LPN #602 had resigned his position from the facility. Further review of the police report revealed photographs of Resident #241 showing two wound treatment dressings to the right upper arm above the elbow dated 09/16/25 3-11 shift, and one wound dressing to the right upper forearm dated 09/16/25 7-3 shift. On the resident's left posterior upper arm above the elbow was a wound dressing dated 09/16/25 3-11 shift and a second wound dressing to the left lower arm dated 09/16/25 3-11 shift visible. The resident had multiple bruised areas from a previous fall. Review of the staffing schedule dated 09/16/25 for the Memory Care Unit revealed there were two nurses (LPN #602 and LPN #614) and four CNA's assigned to the unit on the 3:00 P.M. to 11:30 P.M. shift. CNA #400 was assigned to Resident #241. Review of a skin observation report dated 09/17/25 revealed the resident had a skin tear to the right upper arm measuring 1 cm in length by one cm in width by 0.1 cm in depth. A second skin tear to the left lower arm measuring two cm in length by three cm in width by 0.1 cm in depth. A third skin tear to the left posterior upper arm measuring three cm in length, five cm in width, with a depth of 0.1 cm. Review of a notification letter dated 09/17/25 revealed LPN #602 was informed and acknowledged placement on administrative leave. Review of an interdisciplinary progress note by ADON #549 revealed she had been called on 09/16/25 at 9:18 P.M. about a statement received by a nursing supervisor of a nursing assistant alleging physical and verbal abuse towards Resident #241 by his nurse. ADON #549 instructed the supervisor to remove the charge nurse from the floor immediately, and requested an RN assessment of the resident, skin sweeps on all residents on the unit and for psychiatric services to be notified. Review of a progress note by ADON #549 dated 09/17/25 at 7:58 A.M. revealed the social worker and herself spoke with the resident's representative about the incident of alleged abuse. Review of a medical provider progress note dated 09/17/25 at 10:21 A.M. revealed the resident was assessed with new orders to send to the emergency room for an acute urology evaluation due to urinary urgency, retention, and hematuria. Further review of the progress notes revealed Resident #241 was sent to the emergency room (ER) and treated for a urinary tract infection and ordered antibiotic treatment. The resident returned to the facility on [DATE] at 6:00 P.M. Subsequent review of the ER laboratory final urinalysis results revealed the resident had no urinary tract infection. Review of a progress note by LSW #473 dated 09/17/25 at 10:49 A.M. revealed Resident #241 was in (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 11/06/2025 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete good spirits and recognized the social worker. The social worker inquired how the resident was doing after the incident from the previous evening and the resident stated everything was fine yesterday and he felt good. Review of an IDT progress note by ADON #549 dated 09/17/25 at 12:09 P.M. and 12:14 P.M. revealed the IDT team met to discuss the resident's skin injury from 09/16/25 and to discuss the alleged incident between the resident and staff member. Interventions were noted as in place and the care plan was reviewed and revised. Review of a documented interview dated 09/17/25 with LPN #602 revealed LPN #602 stated and initialed yes he had been educated on the policy related to abuse, neglect, and misappropriation. LPN #602 documented yes and initialed he had worked on the Memory Care Unit on 09/16/25 on second shift. LPN #602 documented and initialed no he had not witnessed Resident #241 throwing water on the floor in his room. LPN #602 documented and initialed yes he had used inappropriate language while assisting Resident #241, additionally noted was spoke loud because resident hard of hearing. LPN #602 documented and initialed yes to using excessive force that could be viewed as aggressive while assisting Resident #241 and noted grabbed waist band of shorts to help transfer. LPN #602 documented and initialed yes to attempting to assist Resident #241 in/out of the common area recliners during the shift. LPN #602 documented and initialed yes Resident #241 had skin injuries prior to the fall and noted there were two skin injuries and LPN #614 had stated there were three total. LPN #602 documented and initialed no to kicking Resident #241 while he was on the floor. LPN #602's interview statement was signed and dated by him on 09/17/25. Review of a statement dated 09/18/25 at 12:23 P.M. by RN Supervisor #700 revealed he had not witnessed the fall or any abuse. RN Supervisor #700 revealed he arrived on the unit shortly after the incident and was not aware of any allegations of abuse until CNA #400 came to his office to report concerns. RN Supervisor #700 revealed he had entered the Memory Care Unit to complete rounds. LPN #614 requested help as RN Supervisor #700 observed Resident #241 on the floor with LPN #602 standing nearby. RN Supervisor #700 stated LPN #614 and LPN #602 reported the resident was throwing water from a urinal in the hallway. LPN #602 stated Resident #241 had climbed out of his wheelchair and sustained multiple skin tears in his room when he was throwing water. RN Supervisor #700 approached Resident #241 and LPN #[TRUNCATED] Event ID: Facility ID: 366325 If continuation sheet Page 8 of 8