Health inspection·October 11, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #14 and Resident #33 were not notified when they were within $200.00 of their asset limit, and further confirmed no additional letters were sent to Resident #16 prior to 10/01/23 regarding his resident trust account approaching and/or exceeding the asset limit. Review of the Ohio Medicaid Income and Asset Limits for Nursing Homes and In-Home Long Term Care, accessed on 10/12/23 and found at https://www.medicaidplanningassistance.org/medicaid-eligibility-ohio/, revealed individual assets must be under $2,000.00. Review of the policy titled Resident Personal Funds, dated 10/10/23, revealed the facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200.00 less than the resource limit for one person. Further, if the amount in the account, in addition to the value of the resident's other resources, reaches the resource limit for one person, the resident may lose eligibility for Medicaid. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 2 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review, staff interview, and policy review, the facility failed to ensure resident advance directives for code status were accurate. This affected one (#33) of 12 residents reviewed for advance directives. The facility census was 50. Findings include: Review of the medical record revealed Resident #33 had an admission date of 05/19/20 and a readmission date of 01/02/21. Resident #33's diagnoses included atrial fibrillation, cerebral infarction, dementia, chronic pain, and chronic obstruction pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/26/23, revealed Resident #33 had intact cognition. Review of a physician order, dated 11/10/21, revealed Resident #33 had elected a full code status. Review of the electronic medical record code status line for Resident #33 revealed Resident #33's code status was a full code. Review of a physician order, dated 09/12/23, revealed Resident #33 had elected for a Do Not Rescuscitate (DNR) comfort care arrest (DNRCC-A) code status (the provider would treat Resident #33 as any other resident without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions would cease and the DNR Comfort Care protocol would be implemented). Review of Resident #33's care plan, initiated on 09/26/23, revealed Resident #33 requested a DNRCC-A code status. Interventions included for the medical record to reflect the resident's wishes for a DNR code status. Interview on 10/03/23 at 2:02 P.M., with Social Services Director (SSD) #223 revealed SSD #223 was aware of the Resident #33's request to change code status. SSD #223 revealed only a nurse could change a resident's code status in the electronic medical record. Interview on 10/03/23 at 3:26 P.M., with Licensed Practical Nurse (LPN) #203 revealed a resident's code status was found in the electronic medical record on the code status line. Interview on 10/04/23 at 3:59 P.M., with the Director of Nursing (DON) revealed Resident #33 was documented in the electronic medical record (EMR) as a full code status. The DON revealed the physician had signed a DNRCC-A order for Resident #33 on 09/12/23 and the EMR had not been updated to reflect the change in code status. Review of the policy titled Do Not Resuscitate Order, revised 04/2017, revealed the facility would not use cardiopulmonary resuscitation and related emergency measures to maintain life function on a resident when there was a Do Not Resuscitate Order in effect. Further review of the policy revealed no guidelines for updating the medical record after a code status change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 3 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Level of Harm - Minimal harm or potential for actual harm 6. Review of Resident #17's medical record revealed an admission date of 03/10/22. Residents Affected - Some Review of the MDS assessment, dated 07/30/23, revealed Resident #17 had impaired cognition. Observation on 10/02/23 at 2:20 P.M. in Resident #17's room revealed a four inch area of the carpet was frayed by the bathroom door. Interview on 10/02/23 at 2:20 P.M. with Resident #17 revealed she has trimmed the carpet in order to prevent from falling. Interview on 10/02/23 at 2:25 P.M. with Housekeeping Aide (HA) #271 verified the carpet was frayed in Resident #17's room. 7. Review of Resident #18's medical record revealed an admission date of 01/24/22. Review of the quarterly MDS assessment, dated 07/03/23, revealed Resident #18 was cognitively intact. Observation on 10/02/23 at 2:40 P.M. revealed the carpet in the room of Resident #18 had a large amount of wrinkles. The wall to the lower left of the window had a large white area where the wall had been patched but was not painted. Interview on 10/02/23 at 2:40 P.M. with Resident #18 revealed the carpet looked bad and the wall had been like that for some time. Interview on 10/03/23 at 4:58 P.M. with DOH #267 verified the carpet was wrinkled and the wall needed painted in Resident #18's room. 8. Review of Resident #22's medical record revealed an admission date of 01/26/23. Review of the quarterly MDS assessment, dated 08/03/23, revealed Resident #22 was cognitively intact. Observation on 10/02/23 at 11:03 A.M. revealed the wall at the corner of Resident #22's bathroom had an approximately three foot long and six inch wide area of white repaired plaster which was not painted. The bathroom had no toilet paper holder and only had a screw sticking out of the wall. Interview on 10/02/23 at 11:03 A.M. with Resident #22 revealed the wall had been like almost his entire stay at the facility and the toilet paper holder had been missing for over two months. Interview on 10/10/23 at 2:20 P.M. with State Tested Nursing Assistant #251 verified the wall of Resident #22's bathroom had an area that had not been painted as well as verified the lack of toilet paper holder in Resident #22's bathroom. Review of the policy titled Maintenance Service, revised 12/2009, revealed maintenance personnel would maintain the building in compliance with current federal, state and local laws, regulations and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 4 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0584 guidelines. The building would be maintained in good repair and free from hazards. Level of Harm - Minimal harm or potential for actual harm This deficiency represents noncompliance investigated under Complaint Number OH00146367. Residents Affected - Some Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents were provided a clean, comfortable, and homelike environment. This affected eight (#7, #17, #18, #22, #30, #36, #38, and #41) of 14 residents reviewed for environment. The facility census was 50. Finding include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/30/21. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/25/23, revealed Resident #36 had intact cognition. Observation on 10/02/23 at 10:39 A.M. in Resident #36's room revealed there were several stains on the carpet as well as large wrinkles in the carpet. Interview on 10/02/23 at 10:39 A.M., with Resident #36 revealed the carpet had been in bad shape for around the past year. 2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment, dated 09/08/23, revealed Resident #41 had impaired cognition. Observation on 10/02/23 at 10:35 A.M. in Resident #41's room revealed there was approximately a nine inch snag and vertical hole in the carpet in the room with carpet fiber strings still attached. Interview on 10/02/23 at 10:35 A.M., with Resident #41 revealed the carpet had been snagged since she moved into the room. 3. Review of the medical record for Resident #7 revealed an admission date of 02/21/23. Review of the quarterly MDS assessment, dated 08/21/23, revealed Resident #41 had impaired cognition. Observation on 10/02/23 at 12:03 P.M. in Resident #7's room revealed the carpet had multiple stains. Interview on 10/02/23 at 12:03 P.M., with Resident #7 revealed she was sick of the carpet stains, and indicated the carpet stains were there when she moved into the room. Resident #7 revealed she asked for the carpet to be cleaned but it never got done. 4. Review of the medical record for Resident #38 revealed an admission date of 04/18/22. Review of the quarterly MDS assessment, dated 07/28/23, revealed Resident #38 had intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 5 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0584 Observation on 10/02/23 at 11:43 A.M. in Resident #38's room revealed there were multiple stains on the carpet along with wrinkles in the carpet. Level of Harm - Minimal harm or potential for actual harm Interview on 10/02/23 at 11:43 A.M. with Resident #38 revealed the stained carpet bothered her. Residents Affected - Some 5. Review of the medical record for Resident #30 revealed an admission date of 05/27/21. Review of the quarterly MDS assessment, dated 08/24/23, revealed Resident #30 had impaired cognition. Observation on 10/02/23 at 11:47 A.M. in Resident #30's room revealed the carpet was heavily stained next to the resident's bed. Interview on 10/03/23 from 4:48 P.M. through 4:58 P.M., with Director of Housekeeping (DOH) #267 verified the carpets in the rooms of Resident #36, #41, #7, #38, #30 were stained throughout the rooms. DOH #267 also revealed the carpet was rippling and wrinkled in the rooms of Resident #38 and Resident #35 from previously cleaning the carpet causing the carpet glue to no longer hold down the carpet. Review of the policy titled Cleaning/Repairing Carpeting and Cloth Furnishings, revised 12/2009, revealed the carpets would be deep-cleaned periodically (approximately once per month) or more often as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 6 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the comprehensive person centered care plan adequately addressed resident activity preferences/interests and activities of daily living. This affected two residents (#31 and #42) of 15 residents reviewed for care plans. The faciity census was 50. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/15/23, revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care. Resident #31 was not interviewed for her activity preferences. Review of the active care plan for Resident #31 revealed the care plan did not address activities and/or Resident #31's activity preferences. Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #31's care plan did not address Resident #31's interests or desired activities. 2. Review of the medical record for Resident #42 revealed an admission date of 03/23/23 with a diagnosis of dementia. Review of the quarterly MDS assessment, dated 07/06/23, revealed Resident #42 had impaired cognition and required extensive assistance of two people for bed mobility and transfers, and extensive assistance of one person for locomotion. Review of the active care plan for Resident #42 revealed Resident #42 had an activities of daily living (ADL) self care performance deficit related to fatigue and limited mobility. Interventions included encouraging Resident #42 to use the bell to call for assistance and for staff to praise all efforts at self care. Interview on 10/10/23 at 2:07 P.M. with the Interim Director of Nursing (IDON) confirmed Resident #42's care plan did not identify the type and/or amount of assistance Resident #42 needed to complete ADL tasks, such as transferring and eating. Review of the policy titled Comprehensive Care Plans, dated 10/24/22, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives to meet a resident's medical, mental, and psychosocial needs. Additionally, the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 7 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were bathed/showered as scheduled and requested. This affected one (Resident #7) of three residents reviewed for bathing. The facility census was 50. Residents Affected - Few Finding include: Review of Resident #7's medical record revealed Resident #7 had an admission date of 02/21/23. Resident #7's diagnoses included chronic obstructive pulmonary disease, anxiety, depression, and fibromyalgia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/21/23, revealed Resident #7 had impaired cognition. Resident #7 required extensive assistance of two staff for personal hygiene. The assessment indicated the bathing activity had not occurred in the look back period for Resident #7. Review of Resident #7's care plan, dated 03/19/23, revealed the resident had an activities of daily living (ADL) self care performance deficit related to limited mobility. There were no interventions specific to bathing or showering. Review of Resident #7's care plan, dated 09/01/23, revealed the resident was resistive to care related to anxiety. Interventions included if the resident resisted activities of daily living, reassure resident, leave and return at a later time if possible and try again. Review of Resident #7's ADL bathing task documentation, revealed the resident had showers scheduled on Tuesday and Friday mornings. Resident #7 received a shower on 09/05/23, 09/15/23, 09/29/23 and 10/03/23. Resident #7 received a bed bath on 09/08/23, 09/26/23 and 09/28/23. Resident #7 received no shower or bed bath on 09/12/23, 09/19/23 and 09/22/23. Review of Resident #7's nurses note, dated 09/13/23 at 7:37 A.M., revealed the resident had not been showered for four days and the resident refused a shower. Further review of the nurse's notes from 09/03/23 through 10/03/23 revealed no other instances when Resident #7 refused a shower. Interview on 10/02/23 at 11:58 A.M., with Resident #7 revealed staff would sometimes wash her up instead of give her a shower. Interview on 10/04/23 at 3:58 P.M., with the Director of Nursing (DON) revealed there was no documentation to indicate Resident #7 refused showers or was offered a shower on 09/01/23, 09/08/23, 09/12/23, 09/19/23, 09/22/23, 09/26/23 and 09/28/23. Review of the policy titled Resident Showers, last revised 03/29/22, revealed residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety. This deficiency represents non-compliance investigated under Complaint Number OH00146367. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 8 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0679 Provide activities to meet all resident's needs. 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 of Resident #34 revealed an admission date of 06/02/23 with a hospital stay from 07/12/23 to 07/18/23. Diagnoses included dementia without behavioral disturbance, difficulty in walking, generalized muscle weakness, fracture of nasal bones, and encounter for other orthopedic aftercare. Resident #34 was admitted to the skilled nursing facility from the attached assisted living facility after having experienced a fall with a femur fracture. Residents Affected - Few Review of the Minimum Data Set 3.0 (MDS) for Resident #34 dated 06/06/23 revealed the resident was cognitively impaired and required extensive assistance of one staff for transfers and activities of daily living (ADLs). The assessment further revealed the resident nor a family member was not interviewed for preferences for customary routine and activities. Review of the fall risk assessment for Resident #34 dated 06/02/23 revealed her to be a high fall risk. Review of the care plan for Resident #34 initiated on 06/07/23 with no updates, revealed the resident had a diagnosis of dementia and requires adoptions when engaging in activities. Interventions included as follows: engage resident in actives comparable with cognition; offer one on one visits and independent leisure materials of choice; provide adaptation related to cognition (hand over hand, cueing and tasks); remind, invite and encourage resident to participate in leisure of choice. Review of the activity task revealed a daily chronicle was provided daily, resident engaged in only eight group activities over the previous 30 days. The form indicated six family visits and nine days of receiving communion. Review of the facility document titled Activity Participation Review dated 09/14/23 revealed the Attendance and Participation Summary section did not have any documentation. The Activity Plan Review section revealed no changes, appropriate. Goal met. Various observations on 10/02/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants. Various observations on 10/03/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants. Various observations on 10/04/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants. Various observations on 10/05/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 9 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0679 room was State Tested Nursing Assistants. Level of Harm - Minimal harm or potential for actual harm Interview on 10/10/23 at 11:11 A.M. with Activity Assistant (AA) #225 revealed every resident receives a daily newsletter. One on one activities include manicures, talks, and offered materials such as puzzles and magazines. AA #225 could not identify any specific time spent with Resident #34. Residents Affected - Few Interview on 10/11/23 at 9:00 A.M. with Director of Nursing (DON) provided verification the activity care plan for Resident #34 was not person-centered. Review of the facility policy titled Activities dated 02/27/23 revealed special consideration will be provided for residents with dementia, developing meaningful activities including residents who remain isolated in room/bed most of day. Based on observation, record review, staff interview, and review of the facility policy, the facility failed to provide resident-centered activities for two (Residents #31 and #34) of three residents reviewed for activities. The facility census was 50. Findings include: 1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care. Further review of Resident #31's MDS assessment revealed a section for addressing her preferences for customary routine and activities with the following instructions: Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other. The assessment was marked no indicating the resident was rarely/never understood and family/significant other were not available. Review of the contact information for Resident #31 revealed she had two emergency contacts, one of whom was designated as her power of attorney for care. Review of the medical record revealed no attempts to contact Resident #31's emergency contacts regarding her activity preferences. Review of the Activity Initial Interview dated 09/20/23 revealed Resident #31 was not interviewed or assessed for her activity preferences. Review of the current care plan for Resident #31 revealed no goals or interventions in place for activities. Review of the documented activities for Resident #31 revealed she refused an opportunity for group activities five times in the last 30 days, and participated in social activities nine times in the last 30 days resulting in 14 opportunities for social activities in 30 days. Various observations on 10/02/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 10 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room. Various observations on 10/03/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room. Various observations on 10/04/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room. Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #31's medical record showed no attempt to contact Resident #31's family regarding her activities of interest. Further interview confirmed the Activity Initial Interview was not conducted and the care plan contained nothing to address Resident #31's interests or desired activities. Review of the policy, Activities, revised 02/27/23, revealed the policy of the facility was to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Further, each resident's interest and needs would be assessed on a routine basis and activities would be designed with the intent to enhance the resident's sense of well-being, belonging and usefulness and create opportunities for each resident to have a meaningful life. Additionally, special considerations would be made for developing meaningful activities for residents with dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 11 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls with injury. Additionally, the facility failed to update a resident's care plan with person centered fall interventions to potentially prevent future falls. This resulted in Actual Harm for one resident when Resident #34 experienced a fall on 07/12/23 which was not investigated to implement effective interventions to potentially prevent future falls. As a result of the fall, Resident #34 sustained a fracture of the nasal bones and a spleen laceration Grade 3 from this fall. Additionally, the facility failed to complete a fall investigation for Residents #43 and #42 to potentially prevent future falls. This affected three (Residents #34, #43, and #42) of three residents reviewed for falls. Lastly, the facility failed to ensure staff were knowledgeable of a resident's transfer requirements to potentially prevent falls. This affected one (Resident #42) of one resident reviewed for staff competence. The facility census was 50. Findings include: 1. Review of the medical record of Resident #34 revealed an admission date of 06/02/23 with a hospital stay from 07/12/23 to 07/18/23. Diagnoses include dementia without behavioral disturbance, difficulty in walking, generalized muscle weakness, fracture of the nasal bones, and encounter for other orthopedic aftercare. Resident #34 was admitted to the skilled nursing facility from the attached assisted living facility after having experienced a fall with a femur fracture in late May of 2023. Following the fracture, Resident #34 had surgery and was then admitted to the nursing home on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance for transfers and activities of daily living (ADLs). Review of the fall risk assessment dated [DATE] revealed Resident #34 was at high risk for falls. Review of the care plan for Resident #34, initiated on 06/05/23 with no updates, revealed the resident was at risk for injury related to falls due to gait/balance problems. Interventions included the following: PT (physical therapy) evaluate and treat as ordered and PRN (as needed), be sure call light is within reach when in room and encourage to use it before attempting to transfer, and the need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness per therapy recommendations. Review of the progress note dated 07/12/13 at 11:42 A.M. written by the Director of Nursing (DON) revealed Resident #34 was transferred to the ER (emergency room) for an evaluation after a fall. Review of a Skilled/Episodic Note dated 07/12/23 at 1:30 P.M. written by agency Registered Nurse (RN) #352 revealed an ice pack was placed on Resident #34's nose and the resident was transported to the ER for an evaluation and treatment. The resident's skin was intact, and she was dependent for toileting and required substantial/maximal assistance with sit to lying and lying to sitting on the side of the bed. Review of the hospital history and physical dated 07/12/23 revealed Resident #34 fell out of her chair after PT at her nursing home. Resident #34 had baseline dementia and did not remember the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 12 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few She complained of facial pain. The resident denied loss of consciousness, denied hitting her head, however had a facial abrasion, and a small one-centimeter laceration to the bridge of her nose and bilateral ecchymosis (bruising) around her eyes. Resident #34 was also experiencing left sided weakness on the initial examination. A cervical collar was in place related to hitting her head. Per the medication administration record, Resident #34 was on Plavix (anticoagulant) and Aspirin 81 milligrams. The hospital provided diagnoses of solid organ injury splenic laceration Grade 3 and nasal laceration/nasal bone fracture. Interview on 10/10/23 at 3:04 P.M. with Project Manager (PM) #300 revealed when reviewing the facility fall investigation, there were no witness statements documented. PM #300 was not employed at the facility at the time of the fall and investigation so could only go by what was documented. The investigation revealed Resident #34 was in her wheelchair, unable to give location, and an activity staff member, unable to give name, notified the nurse (RN #352). Resident #34 was found face down in front of her wheelchair, conscious. Resident #34 was transported to the ER for evaluation. The report revealed RN #352 completed an assessment (ABCs [airway, breathing, and circulation]) and sent Resident #34 to the ER as soon as possible. The report indicated the fall was unwitnessed, the fall risk assessment was high, and Resident #34 had non-skid socks on. The report indicated RN #352 turned Resident #34 on her back, obtained vital signs (blood pressure and pulse) and placed a cold washcloth on her nose. The skin was broken, and blood was coming from the open area. PM #300 confirmed no witness statements were in the investigation. PM #300 stated the report was initiated on 07/12/23 at 11:00 A.M. The investigation was closed on 07/24/23 by the Executive Director. Interview on 10/10/23 at 3:44 P.M. with Physical Therapy Assistant (PTA) #351 and Therapy Program Manager (TPM) #350 revealed PTA #351 worked with Resident #34 on 07/12/23 from 8:32 A.M. to 9:02 A.M. and toileted her in that time frame. After the session was complete, PTA #351 left Resident #34 in her wheelchair in the common area of the 100 hall. PTA #351 was unsure of whom she had let know (aide or nurse) Resident #34 was in the common area but would not leave the area without having told someone. Interview on 10/11/23 at 9:00 A.M. with the (DON) verified Resident #34's care plan was not revised to include person-centered interventions to prevent future falls, following the fall on 07/12/23. The DON further verified the care plan was not person-centered for Resident #34 and had generic fall interventions listed. Review of the facility policy titled Fall Prevention Program dated 10/20/22 revealed each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When a resident experiences a fall the facility will: assess the resident; complete a post fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicated; document all assessments and actions; and obtain witness statements in the case of injury. 2. Review of the medical record of Resident #43 revealed an admission date of 01/14/23. Diagnoses include progressive supranuclear ophthalmoplegia, Parkinson's disease, abnormalities of gait and mobility, muscle weakness, and bipolar disorder. Review of the quarterly MDS dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff for transfers, bed mobility, and toileting. Walking in the room did not occur. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 13 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of the care plan for Resident #43, initiated 01/17/23, revealed a focus of at risk for injury related to falls due to deconditioning and gait/balance problems. Interventions included as follows: PT evaluate and treat as ordered or PRN; be sure call light is within reach when in room and encourage to use it before attempting to transfer; educate resident/family about safety reminders and what to do if a fall occurs; the need to be evaluated for and supplied appropriate adaptive equipment or devices as needed, re-evaluate as needed for continued appropriateness per therapy recommendations; encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated; ensure resident is wearing appropriate footwear when out of bed; make sure floor/path is clutter free and properly lighted. Review of the progress note dated 07/23/23 at 10:13 A.M. revealed Resident #43 had a witnessed fall. No visual injuries or complaints of pain at the time of the injury. Further review of the medical record revealed no fall investigation to determine the root cause of the fall and identify potential interventions to prevent future falls was completed. Interview on 10/10/23 at 4:53 P.M. with PM #300 revealed no fall investigation had taken place and the only documentation of Resident #43's fall was the progress note dated 07/23/23. 3. Review of the medical record for Resident #42 revealed an admission date of 03/23/23 with diagnoses of cerebral infarction and dementia. Resident #42 was admitted under the care of hospice. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had impaired cognition and required extensive assistance of two people for bed mobility and transfers. Further review revealed Resident #42 had no falls since the previous assessment. Review of the fall risk assessments completed 03/24/23, 05/05/23 and 09/28/23 revealed Resident #42 was at high risk for falls. Review of the care plan for Resident #42 revealed she was at risk for falls. Interventions included keeping the bed in a low position while she was in it and keeping her call light within reach. Further review revealed Resident #42 had an activities of daily life (ADL) self care performance deficit related to fatigue and limited mobility. Interventions included encouraging Resident #42 to use the bell to call for assistance and for staff to praise all efforts at self care. The care plan did not identify the type of assistance Resident #42 needed for transfers. Review of the MDS Kardex Report dated 07/06/23 revealed Resident #42 required extensive physical assistance of two or more people for transfers. Review of the facility's Incident Log revealed Resident #42 fell on [DATE] and 09/28/23. Review of a progress note dated 07/03/23 revealed Resident #42 fell out of bed in her room, was assessed and treated for pain, and the family was notified. Further review of the medical record revealed no evidence a fall investigation was completed. Observation on 10/10/23 at 10:30 A.M. revealed Resident #42 dressed and sitting in her wheelchair. Further observation revealed State Tested Nurse Aide (STNA) #313 pushing Resident #42 in her wheelchair from the dining table to the common area to watch television. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 14 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 Observation on 10/10/23 at 10:41 A.M. revealed Resident #42 in her room sleeping in a recliner. Level of Harm - Actual harm Interview on 10/10/23 at 10:44 A.M. with STNA #313 revealed she worked for a staffing agency, but worked frequently enough at the facility to be familiar with Resident #42. STNA #313 stated Resident #42 was able to transfer from the wheelchair to the recliner with one staff providing assistance, and STNA #313 transferred Resident #42 by herself from the wheelchair to the recliner where Resident #42 was sleeping. Residents Affected - Few Interview on 10/10/23 at 1:41 P.M. with the Interim Director of Nursing (IDON) revealed she spoke with the nurse who wrote the progress note on 07/03/23 and confirmed Resident #42 fell on [DATE]. The IDON stated the nurse was busy and failed to complete an incident report or Fall Risk Assessment after Resident #42's fall. The IDON confirmed the facility was unaware of Resident #42's fall on 07/03/23 and did not conduct an investigation into the fall. Interview on 10/10/23 at 2:07 P.M. with the IDON confirmed Resident #42's care plan did not reflect the type and amount of assistance Resident #42 needed to complete ADL tasks, such as transferring. Continued interview with the IDON revealed STNAs relied on the kardex to determine the type of assistance each resident required for ADL tasks. Continued interview with the IDON confirmed the MDS Kardex Report for Resident #42 revealed she required extensive physical assistance of two people for transfers. Review of the policy, Fall Prevention Program, revised 10/20/22, revealed the nurse would indicate on the care plan and the kardex the resident's fall risk and interventions. Further review revealed after a fall, the facility would complete a post-fall assessment, complete an incident report, and document all assessments and actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 15 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received medications as ordered. This affected one (Resident #49) of six residents reviewed for medication administration. Further, the facility failed to separate and dispose of medications for discharged residents and expired residents. This affected three (Residents #306, #307, and #308) of three discharged residents and one (Resident #14) of one resident reviewed for expired medications. The facility census was 50. Findings include: 1. Review of the medical record for Resident #49 revealed an admission date of 08/09/23 with a diagnosis of type two diabetes mellitus. Review of a physician order dated 08/09/23 revealed Resident #49 should receive insulin glargine (to lower blood sugar) subcutaneous (below the skin) solution pen-injector 100 units per milliliter (ml); inject 20 units subcutaneously at bedtime for diabetes mellitus. Review of the October 2023 Medication Administration Record (MAR) for Resident #49 revealed a 9 documented on 10/09/23 for insulin glargine scheduled for 9:00 P.M. Review of the Chart Code on the MAR revealed 9 indicated Other/See Nurse Notes. Review of the progress note dated 10/09/23 at 11:26 P.M. revealed the insulin glargine was on order. Review of the facility provided list of contingency (if needed) insulin available revealed insulin glargine was available. Interview on 10/11/23 at 8:12 A.M. with the Interim Director of Nursing (IDON) confirmed the insulin glargine was not given to Resident #49 and confirmed the medication was available in the contingent medications. 2. Review of the medical record for Resident #306 revealed an admission date of 08/31/23 and a discharge date of 09/15/23. Interview and observation on 10/04/23 at 9:52 A.M. with Licensed Practical Nurse (LPN) #256 revealed her medication cart contained medications for discharged Resident #306, including a bottle of timolol (eye drops), a bottle of latanoprost (eye drops), a bottle of nystatin (to treat mouth infections) and a fluticasone inhaler (to treat breathing problems). LPN #256 stated she worked at the facility for four years and was unsure what to do with medications after residents discharged and confirmed the medications for Resident #306 remained in the cart among current medications for other residents. 3. Review of the medical record for Resident #307 revealed an admission date of 08/16/23 and a discharge date of 09/06/23. Interview and observation on 10/04/23 at 9:52 A.M. with LPN #256 revealed her medication cart contained medication cards (cards with individual punch-out doses of medications) for discharged Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 16 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #307, including two cards of omeprazole (for heartburn relief) 20 milligrams (mg), one card of finasteride (to treat enlarged prostate) 5 mg, three cards of gabapentin (for nerve pain) 100 mg, one card of metoprolol (for high blood pressure) 25 mg, three cards of midodrine (for low blood pressure) 5 mg, one card of Requip (for Parkinson's disease) 1 mg, one card of Requip 0.5 mg, one card of Flomax (for enlarged prostate) 0.4 mg, one card of lopressor (for blood pressure) 25 mg, one card of trazadone (for depression) 50 mg, and a bottle of lidocaine (a numbing liquid). LPN #256 stated she worked at the facility for four years and was unsure what to do with medications after residents discharged and confirmed the medications for Resident #307 remained in the cart among current medications for other residents. 4. Review of the medical record for Resident #308 revealed an admission date of 03/10/23 and a discharge date of 07/20/23. Observation and interview on 10/04/23 at 10:45 A.M. with the IDON of medications stored in the refrigerator revealed two expired medications for discharged Resident #308: vancomycin (an antibiotic) with a use-by date of 04/25/23 and Firvanq (an antibiotic) with a use-by date of 04/04/23. The IDON confirmed the medications were past the use-by date and remained in the refrigerator with medications in use for other residents. 5. Review of the medical record for Resident #14 revealed an admission date of 02/27/19 with a diagnosis of kidney transplant status. Observation and interview on 10/04/23 at 10:45 A.M. with the IDON of medications stored in the refrigerator revealed a bottle of tacrolimus (to reduce organ rejection after a transplant) with a use-by date of 05/03/23 for Resident #14. The IDON confirmed the medication was past the use-by date and remained in the refrigerator with medications in use for other residents. Review of the policy titled, Discontinued Medications, revised 08/2020, revealed when medications were discontinued or the resident was discharged , the medications should be marked as discontinued and stored in a secure and separate area from the active medications until destroyed or returned to the pharmacy. This deficiency represents non-compliance investigated under Complaint Number OH00146367. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 17 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record of Resident #43 revealed an admission date of 01/14/23. Diagnoses include progressive supranuclear opthalmoplegia, Parkinson's disease, abnormalities of gait and mobility, muscle weakness, and bipolar disorder. Review of the quarterly MDS dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff for transfers, bed mobility, and toileting. Walking in room did not occur. Review of the physician orders for Resident #43 revealed an order dated 03/02/23 for Escitalopram oxalate (Lexapro, antidepressant) 10 milligrams (mg) to be administered by mouth one time a day for depression. A second order dated 06/02/23 for Quetiapine Fumarate (Seroquel, antipsychotic) 59 mg to be administered by mouth twice daily for bipolar disorder. Review of the, Consultant Pharmacist Recommendation to Physician, form dated 04/18/23 and 07/25/23 revealed resident has been taking Seroquel 50 mg twice daily since 01/17/23 without a gradual dose reduction. Could we attempt a dose reduction-perhaps to 37.5 mg in the morning and 50 mg at bedtime at this time to verify this resident is on the lowest dose possible? If not, please indicate response below. As of 10/11/23 this has not been addressed by the physician. Review of the, Consultant Pharmacist Recommendation to Physician, form dated 06/19/23 and 09/23/23 revealed this resident has been using Lexapro 10 mg daily since 01/14/23. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. Review of the physician progress notes as of 10/11/23 revealed no response to the request. Interview on 10/11/23 at 7:51 A.M. with the Director of Nursing verified the requests from the pharmacy regarding Resident #43's Seroquel and Lexapro were not addressed by the physician. Review of the policy titled, Medication Regimen Review, dated 08/2020 revealed the pharmacist's monthly recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon the recommendation or rejects and provides an explanation for disagreeing. The policy does not define a timeframe for response from the provider/facility to the pharmacist's recommendations. Based on record review, staff interview, and review of the facility policy, the facility failed to timely respond to pharmacist recommendations. This affected two (Residents #41 and #43) of five residents reviewed for pharmacy recommendations. The facility census was 50. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 01/10/23 with diagnoses of dementia, anxiety, restless legs, and mood disorder due to known physiological condition with major depressive-like episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was rarely/never understood and received an antidepressant seven times during the previous seven days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 18 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0756 Level of Harm - Minimal harm or potential for actual harm Review of a current physician order dated 03/06/23 revealed Resident #41 received Zoloft (an anti-depressant) 100 milligrams (mg) by mouth once daily for anxiety. Review of the progress notes for Resident #41 revealed she was seen by Psych Group #500 to manage her psychotropic (mood altering) medications on 07/05/23 and 08/16/23. Residents Affected - Few Review of the document, Consultant Pharmacist Recommendation to Physician, dated 08/24/23 stated the resident has been using Zoloft 100 mg daily since 01/10/23. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. The document included no response from the physician. Review of the document, Consultant Pharmacist Recommendation to Nursing Staff, dated 05/16/23 revealed Resident #41 had an order for Voltaren gel without a dose (such as 4 grams). The pharmacist requested a dose be included in the physician order. Review of a current physician order dated 06/23/23 revealed Resident #41 received Voltaren Gel 1% (a gel applied to the skin for pain), apply 4 grams topically (on the skin) every six hours for pain. Interview on 10/10/23 at 4:04 P.M. with Director of Social Services #223 confirmed Psych Group #500 had not provided services to Resident #41 since 08/16/23 and therefore no additional progress notes regarding Zoloft were available in the medical record. Interview on 10/11/23 at 7:53 A.M. with the Interim Director of Nursing (IDON) confirmed the Voltaren gel order was updated on 06/23/23 after the pharmacist's recommendation dated 05/16/23 (over one month later). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 19 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation of medication pass, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (#35) of one observed to receive insulin. The facility identified four residents who receive insulin in the 100 hall. The facility census was 50. Residents Affected - Few Findings include: Review of the medical record of Resident #35 revealed an admission date of 09/02/23 with a diagnosis of type II diabetes mellitus without complications. Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus. Observation on 10/04/23 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a blood glucose on Resident #35 of 123 millimeters of mercury. LPN #256 obtained a pen of Insulin Glargine from the medication cart, verified the resident's name and expiration date and dialed the pen to 23. LPN #256 proceeded to and inject the 23 units in the resident's left arm. LPN #256 did not prime the insulin pen prior to administration. Interview at the time of observation with LPN #256 verified she did not prime the insulin pen prior to administration. Review of the facility supplied instructions for insulin administration, Instructions for Use, dated 11/22 revealed it was important to prime the insulin pen before each injection so that it will work correctly. Additional review revealed, If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units and push the dose n=knob in until it stops. You should see insulin at the tip of the needle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 20 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure refrigerated medications were stored at an appropriate temperature. This affected one (Resident #37) and had the potential to affect 12 residents with refrigerated medications. The facility identified 12 (Residents #1, #2, #5, #11, #14, #15, #22, #29, #30, #35, #37 and #41) who had refrigerated medications. The facility census was 50. Findings include: Review of the medical record for Resident #37 revealed an admission date of 04/07/22 and a readmission date of 04/21/23 with a diagnoses of type two diabetes mellitus. Review of a physician order dated 09/21/23 revealed Resident #37 received Novolog FlexPen Subcutaneous Solution Pen-Injector 100 units per milliliter (ml) (insulin aspart), inject 18 units subcutaneously one time a day related to type two diabetes mellitus. Observation and interview on 10/04/23 at 10:45 A.M. with the Interim Director of Nursing (IDON) revealed the locked medication room had one small and one large refrigerator for storing residents' medications. Observation of the temperature logs for October 2023 revealed no temperature was documented on either refrigerator. Continued observation revealed inside the small refrigerator, there was a thermometer with an ice crystal stuck to the top suction cup and a clear liquid inside the face of the thermometer. An additional observation revealed two boxes of Novolog flex pens, for Resident #37, were rubberbanded together. The tops of both boxes had ice coating the boxes in such a way that it was difficult to open the boxes until the ice thawed. Continued observation after the ice thawed revealed eight Novolog flex pens were contained in the two iced boxes. The IDON confirmed there was ice on the thermometer, liquid moving inside it, and two boxes of Novolog flex pens for Resident #37 were iced over. No additional medications were observed to have ice on them. Additional boxes of Novolog flex pens for Resident #37 were available. Review of the temperature logs for the medication refrigerators from July 2023 through September 2023 revealed the facility could provide only one set of logs and could not determine which refrigerator temperatures (the large or small one) was documented on the log. Further review of the log revealed instructions for staff to document the temperature twice daily. Continued review revealed the temperatures were not documented at all on 07/21/23, 07/22/23, 07/24/23, 07/25/23, 08/10/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, 08/24/23, 08/26/23, 08/27/23, 08/30/23, 08/31/23, 09/05/23, 09/09/23, and 09/13/23. Additionally, there were no days when the temperature was documented twice daily, per instructions. Interview on 10/05/23 at approximately 10:00 A.M. with the IDON confirmed the facility could not provide temperature logs for both medication refrigerators from January 2023 through September 2023, and could not determine which refrigerator's temperatures were documented on the logs. Further, the IDON confirmed the temperatures were not documented per instructions. Additionally, no temperatures were documented for either medication refrigerator for 10/01/23, 10/02/23, 10/03/23 and 10/04/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 21 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 Review of the undated policy titled, Medication Storage Information, revealed a refrigerator temperature log must be posted on outside of refrigerator and logged daily. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 22 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, medical record review, staff interview, and review of the menu spreadsheet, the facility failed to provide a pureed meal as approved by the dietitian for four (Residents #11, #21, #28, and #42) of four reviewed for pureed diets. The facility was 50. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/30/21. Review of the physician orders for Resident #11 revealed an order dated 08/06/21 for a regular diet, pureed texture. 2. Review of the medical record for Resident #21 revealed an admission date of 06/23/20. Review of the physician orders for Resident #21 revealed an order dated 07/14/22 for a regular diet, pureed texture. 3. Review of the medical record for Resident #28 revealed an admission date of 07/04/22. Review of the physician orders for Resident #28 revealed an order dated 07/30/22 for a regular diet, pureed texture. 4. Review of the medical record for Resident #42 revealed an admission date of 03/23/23. Review of the physician orders for Resident #42 revealed an order dated 05/01/23 for a regular diet, pureed texture. Review of the dietary spreadsheet dated 10/04/23 revealed the pureed meal to be served with gyro sandwiches served on pita bread with gyro meat, onion, lettuce, and tomatoes, with sweet potato fries. Observation on 10/04/23 at 10:50 A.M. with Director of Dietary (DD) #235 revealed he prepared four plates of pureed gyro meat, pureed sweet potatoes, and pureed peas (as a substitute for the lettuce, tomato, and onions). No pureed pita bread was served to the four residents. Interview on 10/04/23 at 10:55 A.M. with DD #235 revealed he did not puree pita bread and therefore did not follow the planned meal for pureed meals. The facility did not provide a policy for following dietitian approved meals. This deficiency represents non-compliance investigated under Complaint Number OH00146367. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 23 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to maintain the kitchen in a sanitary manner and failed to serve meals in a sanitary manner to potentially prevent foodborne illnesses. This had the potential to affect all 50 residents who received food from the kitchen. The facility census was 50. Findings include: 1. Observations and interview during an initial tour of the kitchen on 10/02/23 at 8:22 A.M. along with Director of Dietary (DD) #235 revealed the following concerns: • Two rolling large trash receptacles were observed to have no lid. DD #235 obtained one lid from behind a rolling metal cart. The lid was noted to have a large amount of oily looking grease on both sides and black substances on the rim. DD #235 placed the lid in the sink. • The smaller, reach-in refrigerator had a moderate amount of food particles laying on the floor, and a large amount of dried food smeared on the door, the door handles, and the inner frame. Small dessert dishes were stored on an open shelf with the inside facing up. • A small chest-type freezer, holding ice cream, had a small dish of ice cream without a cover or date, and a large container of ice cream with the lid halfway crushed in, exposing ice cream. • The wall behind the small freezer had a pink substance dried on it. • The oven had a large amount of dried, baked-on food particles on the floor. • The floor drain, beneath a large electric pot, had a large amount of debris in the drain screen. DD #235 stated the drain grate was tack-welded in place with no way to clean the drain screen. This surveyor lifted the grate with ease. • Both of the gas stoves had a fair amount of food debris around the burners. 2. Observation on 10/02/23 at 11:50 A.M. of meal service in the 300 hall kitchenette revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 24 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many [NAME] #310 wearing gloves. [NAME] #310 rummaged through a drawer with papers and various items, touched the handles of cupboards and the heated serving cart, and proceeded to touch pita bread, to be served to a resident, with the same gloved hand. [NAME] #310 was then observed to grab meat and diced vegetables with the same gloved hand, and placed on the pita bread. [NAME] #310 never changed his gloves after touching non-food items and food items. Interview at the time of observation with [NAME] #310 verified he touched numerous surfaces and then resident food using the same gloved hand. Observation on 10/02/23 at 12:05 P.M. of meal service in the 200 hall kitchenette revealed [NAME] #257 wearing gloves and touching various surfaces, including cupboard handles and papers and then grabbing pita bread and the vegetable toppings with the same gloved hand. Interview at the time of observation with [NAME] #257 confirmed she touched various surfaces and then resident food items with the same gloved hand. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 25 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on review of the Payroll-Based Journal (PBJ) staffing data report, review of staffing schedule, review of an employee time card, staff interview, and policy review, the facility failed to ensure staffing information submitted for the PBJ report was accurate. This had the potential to affect all residents. The facility census was 50. Findings include: Review of the PBJ staffing data report for 01/01/23 through 03/31/23 revealed the facility had no Registered Nurse (RN) coverage on 03/04/23. Review of the facility schedule dated 03/04/23 revealed agency Registered Nurse (RN) #312 was scheduled from 2:00 P.M. to 10:00 P.M. Review of the employee timecard for RN #312 revealed the nurse worked from 2:00 P.M. to 10:03 P.M. Interview on 10/04/23 at 5:30 P.M., the Project Manager (PM) #300 revealed the facility incorrectly submitted data to the PBJ for RN #312. PM #300 stated the nurse was entered into the PBJ as a licensed practical nurse and should have been entered as a registered nurse. Review of the policy, Staffing, revised 10/2017, revealed direct care staffing information per day (including agency and contract staff) would be submitted to the CMS payroll-based journal system on the schedule specified by CMS but no less than once a quarter. Review of the policy, Reporting Direct-Care Staffing Information (Payroll-Based Journal), revised 10/2017 revealed for auditing purposes, reported staffing information was based on payroll records, or other verifiable information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 26 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn when obtaining a blood glucose level and injecting insulin to one resident (#35) of two observed for receiving insulin and having blood glucose level monitored. The facility further failed to ensure the glucometer was disinfected after use. Additionally, the facility failed to ensure staff appropriately completed hand hygiene following the completion of incontinence care. This affected one resident (#28) of six reviewed for activities of daily living (ADLs). The facility census was 50. Residents Affected - Some Findings include: 1. Review of the medical record of Resident #35 revealed an admission date of 09/02/23. Diagnosis of type II diabetes mellitus without complications. Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus. Observation on 11/03/23 at 7:40 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a glucometer from the medication cart and used it to monitor the blood glucose level for Resident #35. LPN #256 did not put on gloves prior to pricking the finger of Resident #35 and obtaining a blood sample applied to the test strip. LPN #256 placed the glucometer back into the medication cart without having disinfecting the device. Interview with LPN #256 provided verification she had not worn gloves to monitor Resident #35's blood sugar, injected the insulin into his left arm and did not disinfect the glucometer after use. Review of the facility policy titled, Personal Protective Equipment, dated 03/02/23 revealed gloves would be worn when direct contact with blood is anticipated. Review of the facility policy titled, Glucometer Disinfection, dated 10/24/22 revealed the facility shall ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturers' instructions for multi-use residents. 2. Review of the medical record for Resident #28 revealed an admission date of 07/04/22 with a diagnosis of Alzheimer's disease. Review of the quarterly Minimum Data Set assessment, dated 07/11/23, revealed Resident #28 was cognitively impaired and required extensive assistance of one staff for personal hygiene. Observation on 10/02/23 at 1:20 P.M. of State Tested Nursing Assistants (STNA) #209 and #251 providing incontinence care for Resident #28 revealed they completed incontinence care and did not change their gloves after performing incontinence care. The observation further revealed upon the completion of incontinence care, STNA #209 and STNA #251 proceeded to arrange the clothing and bed linens for Resident #28 however neither STNA #209 and STNA #251 completed hand hygiene or changed their gloves after completing incontinence care for Resident #28 and prior to arranging Resident #28's bed linens and clothing. Interview on 10/02/23 at 12:30 P.M. with STNA #209 and STNA 251 verified they did not change their gloves after completing incontinence care and prior to arranging Resident #28's bed linens and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 27 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 clothing. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Personal Protective Equipment, dated 03/02/23, revealed change gloves and perform hand hygiene between clean and dirty tasks and when moving form one body part to the anther. Residents Affected - Some This deficiency represents non-compliance investigated under Complaint Number OH00146367. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 28 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the pneumococcal vaccine. This affected three (Residents #22, #41, and #47) of five residents reviewed for pneumococcal vaccination. The facility census was 50. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the immunizations for Resident #22 revealed no information regarding a pneumococcal vaccination. 2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 had impaired cognition. Review of the immunizations for Resident #41 revealed no information regarding a pneumococcal vaccination. 3. Review of the medical record for Resident #47 revealed an admission date of 05/01/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #47 had impaired cognition. Review of the immunizations for Resident #47 revealed no information regarding a pneumococcal vaccination. Interview on 10/05/23 at 9:21 A.M. with Interim Unit Manager #314 confirmed the facility could provide no evidence Resident #22, Resident #41 and Resident #47 were offered the pneumococcal vaccine. Review of the policy titled, Pneumococcal Vaccine (Series), dated 03/02/23, revealed each resident would be offered a pneumococcal immunization unless it was medically contraindicated or the resident had already been immunized. Additionally, the resident's medical record shall include documentation that indicates at a minimum, the following: the resident or representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization and the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 29 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the COVID-19 vaccine or booster vaccine. This affected four (Residents #22, #33, #41, and #47) of five residents reviewed for COVID-19 vaccination. The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the immunizations for Resident #22 revealed he received a COVID-19 booster vaccine on 10/22/21. 2. Review of the medical record for Resident #33 revealed an admission date of 01/02/21. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had impaired cognition. Review of the immunizations for Resident #33 revealed she received a COVID-19 vaccine on 01/04/21 and 01/25/21. Additionally, the documentation revealed Resident #33 received a historical COVID-19 vaccination on 08/02/23, however, there was no evidence the vaccine was administered. 3. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 had impaired cognition. Review of the immunizations for Resident #41 revealed she received a COVID-19 vaccination booster on 11/03/21. 4. Review of the medical record for Resident #47 revealed an admission date of 05/01/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #47 had impaired cognition. Review of the immunizations for Resident #47 revealed no information regarding the COVID-19 vaccination. Interview on 10/05/23 at 9:21 A.M. with Interim Unit Manager #314 confirmed the facility could provide no evidence Resident #22, Resident #41 and Resident #47 were offered COVID-19 vaccination or booster while residing in the facility, and confirmed she could find no evidence Resident #33 received a COVID-19 vaccination booster on 08/02/23. Review of the Centers for Disease Control (CDC) guidelines for COVID-19 booster revealed the bivalent booster (for COVID-19 vaccination and to protect against variants Omicron BA.4 and BA.5) was available and recommended from 09/01/22 until 09/11/23. Websites accessed 10/12/23: https://www.cdc.gov/media/releases/2022/s0901-covid-19-booster.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. Review of the policy titled, COVID-19 Vaccination, revised 05/09/23, defined up to date as a person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366410 If continuation sheet Page 30 of 31 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 366410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Clare Commons 12469 Five Point Road Perrysburg, OH 43551 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete who had completed a COVID-19 vaccine primary series and received the most recent booster dose recommended by the CDC. Further, the vaccine will be offered to residents when supplies are available, as per the CDC and/or FDA (Food and Drug Administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this timer period, or refuses to receive the vaccine. Additionally, the resident's medical record will include documentation regarding education regarding the risks, benefits, and potential side effects and each dose of the vaccine administered to the resident. Event ID: Facility ID: 366410 If continuation sheet Page 31 of 31