Health inspection·January 30, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, resident representative and staff interviews, review of laboratory test results, and facility policy review, the facility failed to notify one resident's representative (Resident #7) of laboratory test results. The facility also failed to notify one resident's (Resident #7) physician/nurse practitioner/physician assistant or resident representative a lab was not completed as ordered. This affected one (Resident #7) of one reviewed for notification of change. The facility census was 108. Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the emergency contacts for Resident #7 revealed the resident's daughter (Daughter #301) was the resident's primary emergency contact and the resident's Durable Power of Attorney (DPOA). Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition and scored a seven out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #7 required assistance ranging from partial assistance to dependence on staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated November 2023 revealed Resident #7 had an order for a Complete Blood Count (CBC), Basic Metabolic Panel (BMP), and B-Type Natriuretic Peptide (BNP) Test one time only for edema, hypertension, and weakness for three days dated 11/22/23 at 12:45 P.M. The lab tests were marked completed on 11/24/23 at 5:24 A.M. An additional order for Resident #7 to check BMP, check potassium level one time only for two days was dated 11/28/23 at 7:00 P.M. The lab order was marked as other see notes on 11/28/23 at 11:32 P.M. Review of the progress notes dated from 11/01/23 through 01/24/24 revealed on 11/22/23 at 2:10 P.M., the Physician Assistant (PA) was in for rounds and ordered Lasix 20 milligrams (mg) orally daily for three days and lab work. Daughter #301 was notified. There was no follow up note related to the results of the lab work or that Daughter #301 was notified of the results. On 11/28/23 at 8:27 P.M., a new order to recheck Basic Metabolic Panel (BMP), check potassium level was received. Daughter #301 was notified. There was no follow up note related to the results from the lab work or that the physician/nurse practitioner/physician assistant or Daughter #301 was notified of the results. Review of the care plan revised 01/11/24 for Resident #7 revealed the resident had altered health maintenance related to progressive physical and mental status. Interventions included monitor labs as ordered and report results to the physician. Review of the BMP, CBC, and BNP lab results reported on 11/25/23 revealed Resident #7 had a high potassium level of 5.3 (normal levels ranged from 3.5 to 5.1 mmol/L). The Physician Assistant was notified. Review of the BNP lab results reported on 11/27/23 at 9:12 A.M. revealed Resident #7 had a high BNP value of 108 pcg/mL (normal levels ranged from 0-100 pcg/mL). The Physician Assistant was notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 2 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 There was no BMP lab results provided for the lab ordered on 11/28/23. Level of Harm - Minimal harm or potential for actual harm Interview on 01/22/24 at 2:44 P.M. with Daughter #301 revealed the facility did not always notify her of changes related to Resident #7. Daughter #301 stated the facility had completed blood work for Resident #7 recently but had not followed up with her since to notify her of the results of the blood work. Residents Affected - Few Interview on 01/25/24 at 7:52 A.M. with the Director of Nursing (DON) and Regional Nurse (RGN) #292 confirmed there was no evidence Daughter #301 was notified of the results of the lab results dated 11/25/23. The DON and RGN #292 confirmed the BMP lab ordered on 11/28/23 had not been completed as ordered and there was no evidence the physician/nurse practitioner/physician assistant or Daughter #301 had been notified the lab was not completed as ordered. Review of the facility policy, Change of Condition, revised 04/2013, revealed the policy stated, A change of condition is defined as deterioration in the health, mental, or psychosocial status of a resident related to a life-threatening condition, a significant alteration of treatment, or a significant change in the resident's clinical condition or status. A significant alteration in treatment is defined as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment, or the decision to transfer a resident to a hospital. The Unit Supervisor or Charge Nurse will notify the resident, physician, and guardian/interested family member of all changes as stated above and of any other situations requiring notification. The person doing the notification may document all notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 3 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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** 3. Review of the medical record for Resident #96 revealed an admission date of 03/01/23 with cognitive deficits. Diagnoses included dementia, unspecified glaucoma, constipation, and chronic pain. Residents Affected - Few Review of Resident #96 nurse's progress notes revealed on 12/19/23 Resident #96 fell out of her wheelchair when leaning over to pick something off the floor. She was diagnosed with a compression fracture to L1&L2. When she returned to the facility, she received physical and occupational therapy. Observation and interview on 01/22/24 10:15 A.M. with Resident #96 revealed she was in her bed wearing a back brace over her clothes. She denied any concerns. Observation and interview on 01/24/24 04:24 P.M. with Resident #96 revealed she was wearing a back brace and had no concerns. Observation and Interview on 01/25/24 at 07:55 A.M. with Resident #96 revealed she was wearing a back brace over her pajamas and a robe. She complained of no pain. Interview on 01/24/24 at 4:30 P.M. with STNA's #210 and #234 confirmed Resident #96 wears the back brace daily. Interview on 01/25/24 at 7:50 A.M. with Physical Therapist # 116 confirmed Resident #96 wears the back brace daily for comfort and pain control. She verified Resident #96 does not have a physician order to wear the back brace since receiving it on 12/20/23. She denied educating the staff on how the resident should wear the brace and how to place the brace on the resident. Interview on 01/25/24 at 8:52 A.M. with STNA # 252 confirmed she does not put the back brace on Resident #96, she believes the physical therapist places it on. She denied being educated on when Resident #96 should wear the back brace or how to place the brace on Resident #96. Review of Resident #96 physician orders dated 01/01/24 to 01/31/24 revealed no order for a back brace. Review of the Resident #96 Plan of Care last updated on 01/08/24 revealed no plan for Resident #96 to wear a back brace. Review of Resident #96 Treatment Administration Records from 01/01/24 to 01/31/24 revealed no instruction for using a back brace. Review of the Physician Orders-Telephone and Verbal Policy dated 08/16/10 revealed the facility must receive and transcribe physician orders in accordance with professional standards of practice. Based on observation, interview, record review and facility policy review, the facility failed to implement preventative skin interventions to prevent repeated skin infections for Resident #85. Additionally, the facility failed to timely assess a bruise for one resident (Resident #4) and failed to implement physician order for a back brace for one resident (Resident #96). This affected two residents (Resident #4 and #85) out of four residents reviewed for skin integrity and one resident (Resident #96) out of three residents reviewed for positioning devices. The facility census was 108. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 4 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 Findings Include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #85 revealed Resident #85 was admitted to the facility on [DATE] with admitting diagnoses including Huntington's Disease, depressive disorder, disorders of the bladder, overactive bladder, impaired communication, and anxiety. Resident #85 required assistance from staff for activities of daily living (ADL) tasks. Residents Affected - Few Review of Resident #85's quarterly [NAME] Data Set (MDS) dated [DATE] revealed resident had rejection of care for one to three days and was frequently incontinent of bladder. Review of Resident #85's care plan dated 11/10/21 revealed alteration in elimination of bladder and bowel incontinence. Resident #85 may require assistance with ADLs and may be at risk for developing complications associated with decreased self-performance. Resident #85 is at risk for alteration in skin integrity with interventions including provide skin care as needed, provide assistance with ADLs, and complete skin assessments per facility policy. Review of Resident #85's physician orders revealed a signed order dated 10/13/23 for antibiotic Bactrim DS 800/160 milligrams two times daily for seven days for skin infection. Further review revealed a signed order dated 01/16/24 for antibiotic Bactrim DS 800/160 milligrams two times daily for seven days for skin infection. Observation on 01/23/24 at 2:23 P.M. revealed Resident #85 lying in bed on a blue uncovered mattress. There was no covering or fitted sheet on the mattress. Resident #85 was dressed in a short sleeved short and lounge pants with slip-on shoes and no socks. Resident #85's upper extremities were uncovered with elbows and forearms in direct contact with the uncovered mattress. Observation on 01/24/24 at 8:58 A.M. revealed Resident #85 lying in bed with a blanket covering from the waist to feet. Resident #85's upper body and arms are uncovered with elbows and forearms in direct contact with the uncovered mattress. Observation on 01/25/24 at 8:07 A.M. revealed Resident #85 lying in bed wearing a short sleeve short and a blanket is covering from the chest down to lower legs. Resident #85 is wearing soft slip-on shows with no socks. Resident #85's uncovered elbows and forearms are in direct contact with the uncovered mattress. Interview on 01/24/24 at 10:37 A.M. with Physician Assistant (PA) #294 revealed Resident #85 had developed atypical areas to both elbows due to spending majority of time lying in bed and using elbows to move around in bed. Assessment of both elbows revealed there was excoriation (worn off skin resulting in an abrasion) and redness in color. Interview on 01/25/24 at 8:07 A.M. with State Tested Nursing Assistant (STNA) #182 revealed Resident #85 will refuse incontinence care and cleaning of the mattress due to urine incontinence. Resident #85 prefers no sheets or coverings on the mattress. When the mattress does have a sheet or covering Resident #85 will either remove or will become entangled in the sheets due to increased body movements related to disease process. STNA #182 stated, We don't do anything other than incontinence care to decrease the friction and moisture from her movements in bed. Interview on 01/25/24 at 12:22 P.M. with PA #294 confirmed Resident #85's areas could be prevented. PA #294 stated Resident #85 had an area to the right elbow a couple of months ago and these current (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 5 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 areas were new but have developed like the previous areas to Resident #85's lower legs due to the friction from continuous movements and the moisture from incontinence. PA #294 was not aware of any skin prevention interventions for Resident #85 since ordering the antibiotic. 2. Review of Resident #4's medial record revealed resident was readmitted to the facility on [DATE] with the admitting diagnoses including major depression, anxiety, bipolar disorder, Chronic Obstructive Pulmonary Disorder (COPD), and seizures. Further review revealed Resident #4 required assistance with activities of daily living (ADL) tasks and had intact cognition. Review of Resident #4's care plan dated 03/22/19 revealed Resident #4 was at risk for alteration in skin integrity. Further review revealed Resident #4 had skin integrity interventions in place including weekly and as needed body checks, complete skin assessments per facility policy, and provide skin care as needed. Review of Resident #4's recent laboratory results revealed Resident #4 had blood collected on 01/17/24 for a Complete Blood Count (CBC) laboratory test. Review of Resident #4's shower documentation dated 01/17/24 to 01/19/24 revealed no new skin areas were observed. Observation on 01/22/24 at 4:05 P.M. revealed Resident #4 with a moderate bruise located on the top and thumb joint area of the left hand. The bruise was dark purple in color and was circular in size, covering approximately one quarter of Resident #4's top of left hand including the first joint of the left thumb. Review of Resident #4's assessments and progress notes date ranges from 01/17/24 to 01/23/24 revealed no evidence of an assessment of skin impairment of the bruise located on top of Resident #4's left hand. Interview on 01/25/24 at 8:00 A.M. with State Tested Nursing Assistant (STNA) #22 revealed if during personal care or bathing tasks, skin impairments including bruises are observed and then reported to the nurse or the Unit Manager. Interview on 01/25/24 at 8:20 A.M. with Registered Nurse (RN) #30 confirmed RN #30 was not aware of Resident #4's bruise to the left hand. RN #30 stated, Usually the STNA's will report any type of skin impairments and/or bruises to myself or the floor nurse. Once the skin impairment has been reported then an assessment is completed, and ongoing monitoring is completed in the progress notes until the area has been resolved. Review of the facility policy titled Skin Assessment revised 09/2017 revealed, Daily, skin is checked during activities of daily living (ADL) care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 6 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, and facility's fall policy, the facility failed to ensure ordered fall interventions were in place. This affected one (Resident #86) of the eight residents reviewed for falls. The facility census was 108. Findings include: Review of the medical record for Resident #86 revealed an admission date of 04/06/21. Diagnoses included Parkinson, hypokalemia, aphasia, seizures, vitamin B 12 deficiency anemia, and hypertension. Review of the plan of care dated 04/22/21 and revised 05/02/23 revealed Resident #86 was at risk for falls due to unsteady gait, Parkinson's, seizures, the use of psychotropic medication, incontinence, needing assistance with activities of daily living (ADL)'s. Interventions include to educate the resident on the use of the call light, keep call light is in reach, extend strips to the shower floor, commonly used articles in reach, keep trash can within reach, non-skid material to top of chair, to toilet, chair near window closet door, shower floor, left side of bed, pull tab to wheelchair, personal sensor alarm to bed, replace alarm box and pad, and shorten string to alarm. Review of Resident #86's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #86 was noted to be free from any bilateral upper or lower extremity impairment and required the use of a walker and/or wheelchair for mobility. Resident #86 required partial to moderate assistance for toilet hygiene, dressing, bed mobility, and transfers, and was noted to be frequently incontinent of bowel and bladder function. Review of orders for Resident #86 revealed the following fall interventions: -Secure a small basket for personal items on bedside table -Non skid material to bed under sheets -PSA to bed -Non skid strops to floor from chair to chair -Ensure bedside table is in reach -Keep trash can in reach -Shortened cord to pull tab alarm -Pull tab alarm to chair, check placement and function every shift -Non skin strips to floor from chair to toilet -May use reacher to obtain items easily (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 7 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 -non skid material to chair Level of Harm - Minimal harm or potential for actual harm -visual reminder to wall in room for resident to ask for assistance -partial assist bar to right side of bed Residents Affected - Few -non skin strip to shower floor -non skid strips in from of chair near window, in front of closet door Review of Resident #86's fall risk assessment dated [DATE] revealed a score of 12.5 indicating the resident was at risk for falls. Review of Resident #86's progress note dated 01/19/24 at 3:24 P.M. created by Social Worker (SW) #86 revealed resident and family was notified that they will be changing rooms temporarily for renovations. Phone call made to family. Resident and family were in agreement and voiced understanding and no care concerns was voiced. Observation on 01/23/24 at 9:57 A.M. of Resident #86 revealed the resident laying sideways in bed with his head hanging over one side and this bilateral lower extremities hanging over the other side of the bed. Resident #86 claimedWe can't eat like this. No personal sensor alarm was noted to the residents bed at this time. Observation on 01/24/24 at 8:42 A.M. revealed non-skin strips were not installed in Resident #86's new room he was currently in due to a recent room change for renovations. Interview on 01/24/24 at 8:50 A.M. with Registered Nurse (RN) #212 confirmed the non-skid strips had not been installed in Resident #86's room yet due to a recent room change. Communication was being completed with the Unit Manager to have this completed. RN #212 confirmed Resident #86 has switched room on 01/19/24 and that the interventions should have been implemented immediately. Review of facility policy titled Fall Management dated 10/17/16 revealed under section titled Follow-Up for Falls: a. Appropriate follow-up will occur as directed by physician orders, facility practice, and the resident's plan of care. c. The need for further evaluation of the resident's health condition, the environment, equipment, medication, staff, resident practices, or other factors will be determined by members of the interdisciplinary team in order to promote a comprehensive plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 8 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #2 revealed an admission date on 05/23/23. Medical diagnoses included cerebral infarction, mild protein-calorie malnutrition, dysphagia oropharyngeal phase, gastro-esophageal reflux disease without esophagitis, dementia, and adult failure to thrive. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had impaired cognition. Resident #2 required substantial/maximal assistance from staff with eating. Resident #2 had a significant weight loss of 5 percent in the last month or a loss of 10 percent or more in the last six months while not on a prescribed weight loss regimen. Resident #2 was 63 inches tall and weighed 97 pounds (lbs). Review of the physician orders dated January 2024 revealed Resident #2 had the following orders in place: Mighty Shakes two times a day with lunch and dinner for supplement dated 01/09/24, Regular pureed textured diet with thin liquids in Blue Provale 5 cc cups with no straws: single sips; upright for meals and for 45 mins following the meal dated 11/15/23, and house supplement three times a day for supplement dated 11/02/23. Review of the weights dated from 05/23/23 through 01/17/24 revealed Resident #2 weighed 121 lbs on 05/23/23, 114 lbs on 07/06/23, 103 lbs on 08/07/23, 101 lbs on 11/08/23, 100 lbs on 12/07/23, 98 lbs on 01/17/24. Review of speech therapy treatment note dated 12/19/23 revealed speech therapist would recommend Provale 5 cc cup to be used at meals for thin liquids. Close supervision recommended during meals. Review of the care plan revised 01/02/24 revealed Resident #2 was non-compliant with eating. Interventions included document educational attempts made with resident in relation to compliance, educated resident and family on negative outcomes related to non-compliance, and notify the physician of non-compliance. Resident #2 had potential for alteration in nutrition and hydration. Significant weight loss times 180 days was noted effective 01/05/24 with a non-significant weight loss noted times 30 and 90 days with poor oral intakes and supplements being received. Interventions included adaptive equipment as ordered, assistance with meals as necessary, dysphagia guidelines as ordered, provide diet as ordered/modified, provide supplement as ordered, speech therapist referral as needed, registered dietitian referral as needed, and weights as ordered. Review of the Nutritional assessment dated [DATE] revealed Resident #2 received a pureed diet with intakes 0-25% at meals with occasional meals at 50%. Resident #2 needed fed at meals and received Blue Provale 5 cc cup to assist self-feeding, resident able to use. Significant weight loss of 17 lbs or 15 percent over 180 days. Question accuracy of July weight (no re-weight was completed). Non-significant weight loss of 4.5 percent over 30 days. Current body mass index of 17.1 indicated underweight for height. Resident was at high risk for decline in nutritional status per Nutrition Risk Tool. Observation and interview on 01/24/24 at 5:30 P.M. with Resident #2 and State Tested Nurse Aide (STNA) #234 of resident's dinner meal tray. STNA #234 confirmed there was not a Blue Provale 5 cc cup on the resident's meal tray. Observation on 01/25/24 from 11:55 A.M. to 12:25 P.M. (30 minutes continuously) during lunch meal service for Resident #2. At 11:55 A.M., Resident #2 was observed laying in bed with her lunch meal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 9 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tray sitting on the bed side table next to the bed. The bed side table was not pulled in front of the resident and the resident's tray was not set up for Resident #2. The resident's entrée remained covered, her silverware was still rolled up, the lids were not taken off her cup of water or apple juice. No staff were observed assisting Resident #2 with eating. At 12:02 P.M., a staff person was observed pushing another male resident in a wheelchair past Resident #2's room. The staff person looked into Resident #2's room but did not say anything to the resident from the hallway. At 12:05 P.M., this surveyor entered Resident #2's room and with the resident's permission sat in a chair in the corner of the resident's room. Resident #2 had a two-handled empty sippy cup, empty Mighty Shake carton, opened chocolate milk carton with approximately 10% of the carton empty, and another cup with a small amount of chocolate milk in it that was not within Resident #2's reach. There were three signs posted behind the resident's bed that stated, no straws, one sip at a time, and seated completely upright for meals and drinks. Resident #2 was observed to have her head of bed slightly elevated at approximately 30 degrees but was not sitting completely upright during the observation. Resident #2 was observed attempting to take drinks from the sippy cups on several occasions but only able to get a few drops that were left in the cup. Resident #2 did not attempt to eat anything. There was not a Blue Provale 5 cc cup observed on her meal tray. No staff came to check on Resident #2, encourage Resident #2 with eating or drinking, provide supervision or offer assistance with eating or drinking until this surveyor intervened at 12:25 P.M. (30 minutes). Review of Resident #2's meal ticket dated 01/25/24 revealed Resident #2 should have a 5 cc Provale Cup and no straws. Observation and interview on 01/25/24 at 12:26 P.M. with Licensed Practical Nurse (LPN) #226 of Resident #2 in her room confirmed no staff was assisting Resident #2 with eating or drinking or providing any supervision of the resident. LPN #226 confirmed there was no Blue Provale 5 cc cup on the resident's meal tray, only a clear sippy cup. LPN #226 moved the resident's bed side table in front of the resident. Resident #2 attempted to take the lid off the cup of water but was unable to do so. LPN #226 assisted with removing the lid. LPN #226 did not raise Resident #2's head of bed so the resident was sitting upright. LPN #226 offered Resident #2 a straw for her water and unwrapped a straw on the resident's tray. At that time, this surveyor intervened and showed LPN #226 the sign that indicated Resident #2 was not to use straws. LPN #226 stated, oh, that is my fault. I did not look. At 12:28 P.M., LPN #226 stated, I would love to be able to feed her but I have to start medication pass. I will have to find someone else to help her. LPN #226 left Resident #2's room at that time unsupervised. This surveyor remained in the resident's room and observed Resident #2 taking several large gulps of water from the uncovered cup followed by coughing. Resident #2 drank approximately 90% of the cup of water by 12:30 P.M. (two minutes) when another STNA arrived. Observation and interview on 01/25/24 at 12:30 P.M. with STNA #246 of Resident #2. STNA #246 also confirmed there was no blue Provale 5 cc cup on the resident's meal tray. STNA #246 confirmed Resident #2 required assistance with eating and drinking. STNA #246 raised the resident's head of bed up until Resident #2 was sitting nearly upright. STNA #246 uncovered the resident's entrée and opened the resident's cup of applesauce. STNA #246 offered Resident #2 a bite of food and the resident accepted it. STNA #246 stated she did not know no one had come to feed Resident #2. This surveyor left Resident #2's room at this time. Review of the facility policy, Medical Nutrition Therapy Best Practices For High Risk Areas-Weight Loss, undated, revealed the policy stated, evaluate the effectiveness of current interventions, assess the resident's ability to eat independently and adequacy of total nutrient intake. Put new intervention in place. Risk factors to consider include functional problems such as swallowing problems, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 10 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contractures, limited range of motion, difficulty with performing ADLs, positioning problems, and difficulty communicating. Based on medical record review, staff interview, observations, and facility policy review, the facility failed to assist residents with eating and implementing nutritional interventions with a noted significant weight loss. This affected two (Resident #2 and #70) of the three residents reviewed for nutritional support. The facility census was 108. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 11/09/22. Diagnoses included dementia, metabolic encephalopathy, encounter for palliative care, and dysphasia. Review of Resident #70's documented weights revealed on 04/06/23 resident weighed 155.4 pounds and then on 04/25/23 the resident weighted 138.4 pounds. This is a noted loss of 17 pounds in less than 30 days. Continued weights after 04/25/23 revealed weights at 138.4 or less. Review of Resident #70's dietary charting revealed no documentation noted to address the sudden 17 pound weigh loss or implementation of interventions to prevent further weight loss. Review of Resident #70's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #70 displayed altered level of consciousness and delusions. Resident #70 required partial to moderate assistance from staff for eating. Resident #70 was noted to be 67 inches tall and weighted 128 pounds with a significant weight loss noted. Interview 01/25/24 at 3:00 P.M. with Dietary Tech #170 revealed there was another Registered Dietitian who was here prior to her coming in and did not follow the appropriate documentation or implementation of interventions for significant weight loss for this resident. There was no charting or documentation noted regarding the noted weight loss. After a significant weight loss there was not follow up weight requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 11 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to post safety signs indicating the use of oxygen outside of oxygen-dependent residents' rooms as required. This affected one resident (Resident #20) who receives oxygen. The facility census was 108. Residents Affected - Few Findings Include: Review of the medical record for Resident #20 revealed the resident was admitted on [DATE] for Urinary Tract Infection, Respiratory disorder, and Acute Respiratory Failure. Review of the Care Plan dated 12/23/23 for Resident #20 indicated the resident receives oxygen therapy. Resident #20 suffers from respiratory deficits caused by a history of Coronavirus disease 19, which includes persistent shortness of breath, pneumonia, and respiratory failure. Review of Resident #20 orders dated 12/24/23 revealed resident is to receive oxygen continuous per nasal cannula to maintain saturation above 90% every shift for hypoxia. Observation on 01/22/24 at 2:47 P.M. revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Observation on 01/23/24 at 7:53 A.M. and 2:57 revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Observation on 01/24/24 at 7:50 A.M. revealed the absence of safety signs indicating the use of oxygen outside of Resident #20 room. Interview on 01/24/23 at 10:05 A.M. with Registered Nurse (RN) #282 stated the resident is currently on oxygen, and Resident #20 does not have a safety signs indicating the use of oxygen outside of the door. RN #282 stated they should be on the door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 12 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication according to the physician's order for one resident (Resident #75). This affected one (Resident #75) of five reviewed for unnecessary medications. The facility census was 108. Residents Affected - Few Findings Include: Review of the medical record for Resident #75 revealed an initial admission date on 03/03/20 and a readmission date on 03/30/23. Medical diagnoses included cerebral palsy, chronic atrial fibrillation, presence of cardiac pacemaker, and hypotension (low blood pressure). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #75 had mildly impaired cognition and scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #75 was independent with completing bed mobility, toileting, and dressing and required supervision or set up help from staff to complete transfers, hygiene, showering/bathing, and eating tasks. Review of the Medication Administration Record (MAR) dated December 2023 revealed Resident #75 had an order for Midodrine Hydrochloride (HCl) 10 milligrams (mg) with instructions to give one tablet by mouth three times daily for hypotension. Hold Midodrine if Systolic Blood Pressure (SBP) was over 130 or Diastolic Blood Pressure (DBP) was over 80 with a start date 06/16/23. The medication was administered on the following dates with the following blood pressure readings: 12/03/23 138/90, 12/08/23 126/87, 12/19/23 132/86, and 12/29/23 132/78. In addition, the medication was held on the following dates with the following blood pressure readings: 12/04/23 116/80 and 12/10/23 124/80. Review of the MAR dated January 2024 revealed Resident #75 received Midodrine HCl 10 mg medication on the following dates with the following blood pressure readings: 01/15/24 143/78 and 01/20/24 124/83. In addition, the medication was held on the following date with the following reading: 01/22/24 120/80. Interview on 01/25/24 at 3:03 P.M. with Regional Nurse (RGN) #292 confirmed Resident #75 received Midodrine HCl medication when his blood pressure was outside the provided parameters. RGN #292 also confirmed Resident #75's medication was held when his blood pressure readings were within the provided parameters and the medication should have been administered. Review of the facility policy, Physician Orders-Telephone and Verbal, revised 08/16/10, revealed the policy stated, physician orders will be received by licensed nurses, pharmacists, therapists and other persons authorized by state law to do so, and will be confirmed in writing by the prescriber with their dated signature. Record the actual order(s) received from the physician in the electronic medical record. Once the order is written, the nurse takes steps to transcribe and note the order. The policy did not address properly following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 13 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of manufacture guidelines the facility failed to remove five expired tuberculin (TB) solution vials from circulation. This had the potential to affect all 108 residents residing in the facility. The facility census was 108. Findings Include: Observation on [DATE] at 1:20 P.M. of unit 400 medication storage refrigerator revealed an opened Aplisol tuberculin (TB) solution vial received from pharmacy on [DATE] with an opened date of [DATE]. Registered Nurse (RN) #212 confirmed the expired opened Aplisol TB solution vial. Observation on [DATE] at 1:30 P.M. of unit 200 medication storage refrigerator revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Further observation revealed another opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Registered Nurse (RN) #282 confirmed the two opened expired Aplisol TB solution vials. Observation on [DATE] at 1:42 P.M. of unit 300 medication storage refrigerator revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with an opened of date [DATE]. Further observation revealed an opened Aplisol TB solution vial received from the pharmacy on [DATE] with no opened date. Licensed Practical Nurse (LPN) #144 confirmed the two opened expired Aplisol TB solution vials. Review of the Aplisol TB solution manufacturer guidelines revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 14 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interviews, and facility policy review, the facility failed to obtain a laboratory test as ordered by a physician for one resident (Resident #7). This affected one (Resident #7) of one reviewed for laboratory tests. The facility census was 108. Residents Affected - Few Findings Include: Review of the medical record for Resident #7 revealed an admission date on 11/16/21. Medical diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), chronic kidney disease Stage 3, and dysphagia (difficulty swallowing) oropharyngeal phase. Review of the annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #7 had impaired cognition and scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #7 required assistance ranging from partial assistance to dependence on staff to complete Activities of Daily Living (ADLs). Review of the Medication Administration Record (MAR) dated November 2023 revealed an order for Resident #7 to check Basic Metabolic Panel (BMP), check potassium level one time only for two days was dated 11/28/23 at 7:00 P.M. The lab order was marked as other see notes on 11/28/23 at 11:32 P.M. Review of the progress notes dated from 11/01/23 through 01/24/24 revealed on 11/28/23 at 8:27 P.M., a new order to recheck Basic Metabolic Panel (BMP), check potassium level was received. Daughter #301 was notified. There were no additional notes related to the results from the lab test. Review of the care plan revised 01/11/24 for Resident #7 revealed the resident had altered health maintenance related to progressive physical and mental status. Interventions included monitor labs as ordered and report results to the physician. Review of the laboratory test results for Resident #7 dated from 01/01/2023 through 01/24/24 revealed there was no BMP lab result provided for the lab ordered on 11/28/23 or after. Interview on 01/25/24 at 7:52 A.M. with the Director of Nursing (DON) and Regional Nurse (RGN) #292 confirmed the BMP lab ordered on 11/28/23 had not been completed as ordered. Review of the facility policy, Physician Orders-Telephone and Verbal, revised 08/16/10, revealed the policy stated, physician orders will be received by licensed nurses, pharmacists, therapists and other persons authorized by state law to do so, and will be confirmed in writing by the prescriber with their dated signature. Record the actual order(s) received from the physician in the electronic medical record. Once the order is written, the nurse takes steps to transcribe and note the order. The policy did not address properly following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 15 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Some 3. Review of the medical record review for Resident #6 revealed an admission date of 05/19/23. Diagnoses included heart failure, peripheral vascular disease (PVD), and primary osteoarthritis. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15 indicating the resident had a severely impaired cognition for daily decision making abilities. Resident #6 was noted to have one unstageable pressure ulcer, one stage II pressure ulcer, and three venous and arterial ulcers. Review of Resident #6's treatment orders dated 01/07/24 revealed the following treatment to be completed, Right upper thigh, cleanse wound with Vashe wound cleanser, pat dry with gauze, apply primary dressing , honey wound gel and cover with secondary dressings, clean dry dressing every night shift for healing and as needed. Observation on 01/25/24 02:01 P.M. of RN #226 completing wound care with the assistance from RN #30 revealed concerns regarding infection control. RN #212 was observed using hand sanitizer upon enter the residents room to completed wound care. Gloves were put on and the old dressing was removed and the wound was cleansed. RN #212 removed the old dirty gloves and put on a pair of new gloves with out completing hand hygiene in between the removal of the soiled gloves and placement of the clean gloves. Interview on 01/25/2024 with RN #226 and #30 confirmed hand hygiene was not completed in between glove changes. Interview on 01/25/2024 at 3:30 P.M. with the Director of Nursing (DON) revealed when a dressing is to be changed hand hygiene should be completed prior and after gloves are changed, if the hands are not visibly soiled, they can use hand sanitizer, if soiled, need to wash with soap and water. Review of facility policy titled Hand Hygiene, dated 11/28/2017 revealed, 6. Staff perform hand hygiene (even if gloves are used) in the following situations: c. after removing personal protective equipment (e.g. gloves, gown, facemask). Based on observation, interview, record review, and policy review, the facility failed to implement infection control measures for the cleaning of glucometers (blood sugar meters) and proper hand hygiene during wound dressing change procedures. This affected two residents (Residents #26 and #108) out of eleven residents requiring blood sugar checks on Units 200 and 300, and one resident (Resident #6) out of three residents reviewed for skin pressure injuries. The facility census was 108. Findings Include: 1. Review of Resident #108's medical record revealed Resident #108 was admitted to the facility on [DATE] with the admitting diagnoses including Diabetes Mellitus type two, high blood pressure, hypothyroidism, and weakness. Resident #108 required limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #108 signed physician orders revealed an order dated 11/01/23 for Novolog (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 16 of 17 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 366353 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuscany Gardens 7400 Hazelton Etna Road SW Pataskala, OH 43062 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 0880 Insulin 100 unit per milliliter administered four times daily per blood sugar check results. Level of Harm - Minimal harm or potential for actual harm Observation on 01/24/24 at 8:10 A.M. revealed Registered Nurse (RN) #282 during morning medication administration for the 200 unit performing blood sugar check for Resident #108. RN #282 sanitized hands and removed the glucometer, several alcohol wipes, lancet, and a bottle of test strips from the medication cart and entered Resident #108's room. RN #282 placed a paper towel for a barrier and then placed the supplies on the barrier. RN #282 donned gloves and performed the finger stick and blood sugar check for Resident #108. RN #282 removed the gloves, washed hands and gathered the remaining supplies and left Resident #108's room. #282 placed the glucometer and the bottle of test strips on the top of the medication cart and disposed of the other supplies. RN #282 washed her hands and then documented the blood sugar results. RN #282 continued the morning medication administration without cleansing the glucometer. Residents Affected - Some Interview on 01/24/23 at 8:25 A.M. with RN #282 confirmed following Resident #108's blood sugar check the glucometer should have been cleaned using disinfectant wipes and following the manufacturer guidelines, and then stored in the medication cart. 2. Review of Resident #26 medical record revealed Resident #26 was admitted to the facility on [DATE] with the admitting diagnoses including history of stroke, high blood pressure, Diabetes Mellites type two, and hyperlipidemia. Resident #26 requires the use of a walker for ambulation assistance and limited assistance from staff for activities of daily living (ADL) tasks. Review of Resident #26's signed physician orders revealed an order dated 02/01/23 for Insulin Aspart 100 units per milliliter administered four times daily per results of blood sugar check. Observation on 01/24/23 at 10:53 A.M. revealed Licensed Practical Nurse (LPN) #144 during noon medication administration for 300 unit performing blood sugar check for Resident #26. LPN #144 donned gloves and removed two alcohol wipes from the medication cart and began wiping the glucometer with the alcohol wipes. After wiping the glucometer, LPN #144 placed the glucometer on a paper towel on top of the medication cart, removed the gloves and sanitized hands. LPN #144 then gathered the rest of the supplies including a finger stick lancet, a test strip, and several alcohol wipes. LPN #144 placed these supplies into two empty plastic cups and entered Resident #26's room. LPN #144 placed a paper towel on the bedside table, placed the supplies on the barrier, washed hands and donned gloves. LPN #144 obtained Resident #26's blood sugar check, removed gloves, washed hands, gathered the remaining supplies, and left the room. LPN #144 placed the glucometer on the barrier on top of the medication cart and disposed of the rest of the supplies. LPN #144 donned gloves and wiped the glucometer with several alcohol wipes, and then stored the glucometer in the medication cart. Interview on 01/24/23 at 1:30 P.M. with LPN #144 confirmed the glucometer should be cleansed with disinfectant wipes per the manufacturer guidelines instead of using alcohol wipes. Review of the facility's policy titled, Cleaning and Disinfection of Capillary-blood sampling devices revised 04/2015 revealed, Cleanse the glucometer with the disinfectant wipe. Allow surfaces to remain wet based on the manufacturer guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366353 If continuation sheet Page 17 of 17