Health inspection·July 8, 2021

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/06/21 at 1:50 P.M. with Resident #232 revealed he had no ability to move his right side and when STNA #107 would care for him she was rough. He stated he could never move fast enough for her and she would cause him pain during care because she was too fast at providing care, and he would need Volteren Gel (referring to Diclofenac Gel) and Aleve (referring to Naproxen) after. He revealed he notified the UM about it and stated she would make a sign to post about staff going slower and taking their time, but she never did. Interview on 07/07/21 at 11:59 A.M. with Registered Nurse (RN)/Unit Manager (UM) #104 revealed Resident #232 is thoroughly unhappy with STNA #107. On 07/06/21, early in the day, Resident #232 stated to her that STNA #107 was rough with him, and she didn't take her time with him. She stated she spoke to the night shift nurses and told them they need to be present when the aides go in to assist him (including STNA #107). She revealed that staff need to do things/care slowly because it hurts him if they go too fast. She spoke to Resident #232 about the plan to have more staff in his room with him during care to assist and staff to be slower with care and he stated he was fine with that response. RN/UM #104 had a conversation with STNA #107 where she told her the concerns that he brought up. She apologized and said she didn't realize she was rough. She stated there was never any issues with STNA #107 and they advised her though to take a nurse with her when she needs to provide care. RN/UM #104 stated she notified the DON and the Administrator of the allegations and she doesn't know why an SRI was never submitted with the state agency. She revealed she did tell him she would make a sign and that she would post it. Interview on 07/07/21 at 12:36 P.M. with the Director of Nursing (DON) revealed they were now doing an investigation for the allegation and getting statements from STNA #107. He stated he was not sure why an SRI was not completed for it. Interview on 07/08/21 at 10:43 A.M. with the Administrator revealed she completed an SRI yesterday (07/07/21) since it was finally conveyed to her that he alleged rough treatment. She stated she spoke to STNA #107 and asked her if he ever asked her to stop providing care and she said no, but he would make oo and ah sounds when washing him, the wife was present, and he never said stop or you're hurting me. She revealed once all the staff came to her yesterday, they started the investigation. She stated he was vague about what day it happened. They are now interviewing other residents and staff currently. The surveyor informed her of the interview on 07/07/21 with RN/UM #104 where she had said that she spoke to Resident #232 on 07/06/21 and he told her staff was rough with him. Review of the SRI #208448, dated 07/07/21 at 3:36 P.M. under the category of neglect/mistreatment revealed the surveyor reported to us today (7/7) that during resident interview on 7/6 the resident stated that a night staff was 'rough' with him during care on Monday evening (7/5). No report was made to staff by resident and so investigation started as of knowledge today. and Resident stated to surveyor that staff 'caused him pain' Staff has been suspended investigation. Review of the undated facility policy and procedure titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed abuse was defined as the wilful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish. It further revealed if a staff member was accused or suspected of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property, the facility will immediately remove the staff from the facility and schedule pending the outcome of the investigation. It further revealed the Administrator or their designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 2 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0607 Level of Harm - Minimal harm or potential for actual harm property and injuries of unknown origin as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. The policy further stated once the Administrator and ODH are notified, an investigation of the allegation violation would be conducted. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 3 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, review of facility Self Reported Incidents (SRI), and facility policy and procedure, the facility failed to ensure the state agency was notified of an allegation of rough treatment and failed to conduct a complete investigation into the allegation. This affected one resident (#232) out of one resident reviewed for abuse. The census was 15. Findings Include: The medical record review for Resident #232 revealed an admission date of 06/10/21 and the diagnoses of cellulitus of right lower limb, diabetes type two, high blood pressure and cerebral infarction. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and he required extensive assistance of two staff for bed mobility, transfers, and toileting, and limited assistance of one staff for personal hygiene. The care plan dated 07/07/21 revealed the resident doesn't like to be rushed during care and would like communication of what is being done during care and would like to be given choices with interventions to communicate with staff when feeling rushed, communicate immediate needs, and staff will communicate with the resident during care to address immediate needs and they will pace themselves during care. The care plan dated 07/06/21 revealed the resident had the potential for pain related to stroke and right lower leg cellulitis with interventions to monitor and record pain characteristics. It further stated the resident had a self care deficit related to stroke with right sided weakness and right lower leg cellulitus requiring assistance with bed mobility, transfers, toileting, bathing and eating with interventions to praise all efforts at self care, therapy evaluations, encourage participation to the fullest extent possible and monitor/document/report any changes, improvements, reasons for deficits, expected course and declines in function. The resident had physician orders for Naproxen 500 milligrams (mg) every 12 hours as needed for pain and Diclofenac Sodium Gel 1% with instructions to apply 4 grams (g) to the knees every six hours as needed for pain. The resident received the PRN Naproxen on 07/03/21, 07/04/21, 07/06/21, 07/07/21, and 07/08/21 and he received the PRN Diclofenac Gel on 07/01/21, 07/02/21, and 07/03/21 for pain ranging from four to seven out of ten (on a zero to ten scale, zero meaning no pain and ten meaning the worst pain). Review of the staff schedule revealed State Tested Nurse Assistant (STNA) #107 worked on 07/02/21, 07/03/21, 07/04/21 and 07/05/21. Interview on 07/06/21 at 1:50 P.M. with Resident #232 revealed he had no ability to move his right side and when STNA #107 would care for him she was rough. He stated he could never move fast enough for her and she would cause him pain during care because she was too fast at providing care, and he would need Volteren Gel (referring to Diclofenac Gel) and Aleve (referring to Naproxen) after. He revealed he notified the UM about it and stated she would make a sign to post about staff going slower and taking their time, but she never did. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 4 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/07/21 at 11:59 A.M. with Registered Nurse (RN)/Unit Manager (UM) #104 revealed Resident #232 is thoroughly unhappy with STNA #107. On 07/06/21, early in the day, Resident #232 stated to her that STNA #107 was rough with him, and she didn't take her time with him. She stated she spoke to the night shift nurses and told them they need to be present when the aides go in to assist him (including STNA #107). She revealed that staff need to do things/care slowly because it hurts him if they go too fast. She spoke to Resident #232 about the plan to have more staff in his room with him during care to assist and staff to be slower with care and he stated he was fine with that response. RN/UM #104 had a conversation with STNA #107 where she told her the concerns that he brought up. She apologized and said she didn't realize she was rough. She stated there was never any issues with STNA #107 and they advised her though to take a nurse with her when she needs to provide care. RN/UM #104 stated she notified the DON and the Administrator of the allegations and she doesn't know why an SRI was never submitted with the state agency. She revealed she did tell him she would make a sign and that she would post it. Interview on 07/07/21 at 12:36 P.M. with the Director of Nursing (DON) revealed they were now doing an investigation for the allegation and getting statements from STNA #107. He stated he was not sure why an SRI was not completed for it. Interview on 07/08/21 at 10:43 A.M. with the Administrator revealed she completed an SRI yesterday (07/07/21) since it was finally conveyed to her that he alleged rough treatment. She stated she spoke to STNA #107 and asked her if he ever asked her to stop providing care and she said no, but he would make oo and ah sounds when washing him, the wife was present, and he never said stop or you're hurting me. She revealed once all the staff came to her yesterday, they started the investigation. She stated he was vague about what day it happened. They are now interviewing other residents and staff currently. The surveyor informed her of the interview on 07/07/21 with RN/UM #104 where she had said that she spoke to Resident #232 on 07/06/21 and he told her staff was rough with him. Review of the SRI #208448, dated 07/07/21 at 3:36 P.M. under the category of neglect/mistreatment revealed the surveyor reported to us today (7/7) that during resident interview on 7/6 the resident stated that a night staff was 'rough' with him during care on Monday evening (7/5). No report was made to staff by resident and so investigation started as of knowledge today. and Resident stated to surveyor that staff 'caused him pain' Staff has been suspended investigation. Review of the undated facility policy and procedure titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revealed abuse was defined as the wilful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish. It further revealed if a staff member was accused or suspected of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property, the facility will immediately remove the staff from the facility and schedule pending the outcome of the investigation. It further revealed the Administrator or their designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown origin as soon as possible but no later than 24 hours from the time the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. The policy further stated once the Administrator and ODH are notified, an investigation of the allegation violation would be conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 5 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to ensure a pressure wound assessment was completed for a coccyx wound and failed to ensure ordered wound treatments were completed. This affected one resident (Resident #126) of the one resident reviewed for pressure wound care and assessment. The facility census was 15. Residents Affected - Few Findings include: 1a. Review of the medical record for Resident #126 revealed an admission date on 06/24/21. Diagnoses included, activated protein C resistance, hypothyroidism, macular degeneration, and hypertension. Review of Resident #126's physician orders for June 2021, and July 2021, revealed: Cleanse resident's coccyx pressure area with normal saline, pat dry, apply Medihoney, cover with Hydro Cellular foam, and cover with adhesive boarder, every day shift. Review of Resident #126's admission, Minimum Data Set (MDS) 3.0, assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had a moderately impaired cognition for daily decision making ability. Resident #126 required extensive assistance from one staff member for toilet use, and personal hygiene and extensive assistance from two staff members for bed mobility, transfers, and dressing. Resident #126 was noted to always be incontinent of bowel and bladder. Review of Resident #126's plan of care dated 07/06/21 revealed the resident has pressure ulcers and potential for pressure ulcer development related to a history of ulcers, and immobility. Interventions included assessment and documentation of wound including measuring length, width, and depth of the wound and the wound bed and healing progress. Review of weekly skin assessments completed for Resident #126 on 06/26/21, 06/28/21, and 07/05/21, revealed no evidence of a coccyx wound. Review of the weekly pressure ulcer record completed on 07/02/21 revealed no evidence of a coccyx wound. Interview on 07/08/21 at 2:30 P.M. with Unit Manager #104 confirmed a pressure wound assessment or skin assessment had not been completed for Resident #126's coccyx wound. Unit Manager #104 stated a wound assessment had been completed for the resident's coccyx pressure ulcer and was able to provide evidence of this, however, Unit Manager #104 confirmed this information had not been documented in the resident's medical record. b. Review of Resident #126's Treatment Administration Record (TAR) for June 2021 revealed the resident's coccyx wound treatment was not completed on 06/26/21, 06/27/21, and 06/30/21. Review of the resident's TAR for July 2021 revealed the coccyx wound treatment was completed on 07/06/21. Interview on 07/08/21 at 2:30 P.M. with Unit Manager #104 confirmed Resident #126's TAR failed to provide documented evidence that her coccyx wound ulcer treatment had been completed on 06/26/21, 06/27/21, 06/30/21, and 07/06/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 6 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a complete fall investigation was completed after a fall had occurred and to ensure fall interventions were in place. This affected one (Resident #126) of the one resident reviewed for falls. The facility census was 15. Findings include: Review of the medical record for Resident #126 revealed an admission date on 06/24/21. Diagnoses included, activated protein C resistance, hypothyroidism, macular degeneration, and hypertension. Review of Resident #126's admission, Minimum Data Set (MDS) 3.0, assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had a moderately impaired cognition for daily decision making ability. Resident #126 required extensive assistance from one staff member for toilet use, and personal hygiene and extensive assistance from two staff members for bed mobility, transfers, and dressing. Resident #126 was noted to always be incontinent of bowel and bladder. Review of Resident #126's plan of care dated 07/06/21 revealed the resident was a high risk for falls related to confusion, gait/balance problems, incontinence, being unaware of safety needs, and vision/hearing problems. Interventions include being sure the call light is within reach, encourage resident to use the call light when assistance is needed, resident needs prompt response, and provide visual and or tactile prompts to ask for help. Review of Resident #126's plan of care dated 07/06/21 revealed resident is at risk for falls due to status post falls. Interventions included to ensure residents bed is kept in the lowest position, call light is available to resident, evaluate fall risk on admission and as needed and if fall occurs alert provider. Review of Resident #126's Fall Risk assessment completed on 06/24/21 due to being a new admission, revealed a score of 16 indicating the resident was a high risk for falls. Review of Resident #126's Fall Risk assessment completed on 06/26/21, completed due to a fall, revealed a score of 17 indicating the resident was a high risk for falls. Risk have been reviewed with the following interventions added to the care plan: low bed floor mat, keep commonly used items within reach, non slip socks, toileting program, wheelchair, assess and medicate for pain as needed. Review of Resident #126's progress note dated 06/26/21 at 3:06 A.M. revealed, fall, multiple skin tears, no head injury reported, fall and wound protocols. Review of Resident #126's progress note dated 06/26/21 at 5:16 A.M. revealed, resident fall risk assessment completed for recent falls. Risk have been reviewed with the following interventions added to the care plan: low bed, floor mat, keep commonly used items within reach, non slip socks, toileting program, wheelchair, and assess and medicate for pain as needed. Review of Resident #126's progress note dated 06/26/21 at 9:12 A.M. revealed, upon assessment for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 7 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's fall, believe resident's arm slid through under the coffee table scrapping the skin and causing a large skin tear. Review of Resident #126's fall investigation completed 06/26/21 at 1:13 A.M. by Registered Nurse (RN) #100, revealed as the floor nurse was walking through the hallway after attending to another resident, noted this resident lying on the floor on her left side beside her bed in-between the bed and the coffee table. Upon arrival , called the resident's name, rolled her on her back, on assessment, noted that the left arm had a large skin tear, the skin was pulled back about 60% of her skin with small amount of bleed. Resident was not able to state how she got on the floor when asked. Action taken, completed a head to toe skin assessment done after transferred back into bed with two person assist and with a gait belt. Left lower arm skin tear cleansed with wound cleanser, pat dry, pulled retraction skin to approximate the edges, applied steri-strips. The other site that was not cover by skin, applied Vaseline gauze, then wrapped it with kerlex, noted three separate skin tears on left knee, right lower arm just above the wrist. All measurements put in skin evaluation assessment. Other skin tears cleansed with wound cleanser, pat dry applied Vaseline gauze, covered with a dry dressing. No other skin issues noted at time of assessment. No bumps on face and scalp, no bruising noted as well. Neuro checks initiated. Vital signs within normal limits, resident positioned for comfort, floor mat placed on floor. Continued review of the fall investigation revealed the resident was alert to person only. The predisposing environmental factors, and predisposing situation factors were not completed. Review of Resident #126's vital signs located in the residents electronic medical record did not reflect neuro-checks were being completed. Review of the resident's paper/hard chart revealed no evidence the neuro-checks were completed. Observations completed on 07/06/21 at 11:18 A.M. of Resident #126 revealed the resident sitting in the recliner in her room. Resident #126 was noted to be wearing a pair of blue and white fluffy socks. Interview on 07/06/21 at 11:20 A.M. with Registered Nurse (RN) #115 confirmed the socks Resident #126 was wearing were not non-slip socks. Review of Resident #126's progress noted date 07/06/21 at 11:41 A.M. revealed, resident's daughter refused for resident to wear grip socks due to tenderness of her feet. Interview on 07/08/21 at 2:30 P.M. with the Administrator revealed Resident #126's daughter did not want the resident to wear non-slip socks but this had not been identified until after the resident had been observed with fluffy socks. The Administrator confirmed the non-skid socks should have been in place at the time of resident's observation completed on 07/06/21 at 11:18 A.M. The Administrator and DON confirmed a fall investigation or incident report could not be located or identified in Resident #126's medical record. The Administrator stated a fall investigation was completed but it was a document that was only able to be reviewed by administration of the system. Continued interview with the Administrator and DON confirmed the fall investigation the facility completed did not contain the resident's vital signs or neuro-checks. Review of the facility policy titled, Assessing Falls and Their Causes, dated 10/2017, revealed un Documentation, When a resident falls, the following information should be recorded in the resident's medical record: The conditions in which the resident was found, assessment date including vital signs and any obvious injuries, interventions, first aid, or treatment administered, notification, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 8 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 completion of a fall risk assessment, appropriate interventions taken to prevent future falls, and the signature and title of the person recording the data. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 9 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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** Based on medical record review and staff interview, the facility failed to complete physician orders following a medication regimen review. This affected one resident (#5) out of five residents reviewed for unnecessary medications. The census was 15. Findings Include: A medical record review for Resident #5 revealed an admission date of 01/02/18 and the diagnoses of hypothyroidism, osteoarthritis, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and the resident required extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene. Review of the residents physician orders revealed she was receiving Levothyroxine (Synthroid) 88 micrograms (mcg) daily for her thyroid. Review of the care plan dated 01/18/18 revealed the resident had the diagnoses of hypothyroidism and received daily replacement therapy with interventions to obtain labs as ordered. Review of the medication regimen review from 01/05/21 revealed the pharmacist recommended drawing a Thyroid Stimulating Hormone (TSH) level every six months since Synthroid was being used and that was the current guideline. The physician agreed and on 01/15/21 a new order was written for a TSH level every six months starting on the 15th for TSH monitoring. Review of the residents labs revealed 05/23/20 was the most recent TSH. Interview on 07/08/21 at 3:05 P.M. with the Director of Nursing (DON) confirmed the resident's TSH lab was not completed in January 2021 and still had not been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 10 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete non-pharmacological interventions prior to as needed (PRN) pain and antipsychotic medications. This affected one resident (#5) out of five residents reviewed for unnecessary medications. The census was 15. Findings Include: A medical record review for Resident #5 revealed an admission date of 01/02/18 and the diagnoses of hypothyroidism, osteoarthritis, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and the resident required extensive assistance of two staff for bed mobility, transfers, toilet use and personal hygiene. Review of the resident's physician orders revealed she was receiving Tramadol 50 milligrams (mg) every six hours as needed for pain, Trazodone 50 mg every 24 hours as needed at night for insomnia, and non-pharmacological intervention documentation with every as needed mediation given. Review of the care plan dated 02/24/20 revealed the resident had the potential for acute and chronic pain related to a femur fracture, gastro-esophageal reflux disease, osteoporosis, osteoarthritis, and kyphosis, she was at risk for experiencing side effects from narcotic analgesics and received routine and as needed medications to manage her pain with interventions to administer analgesics as ordered, encourage her to try different pain relieving methods (relaxation therapy, bathing, heat and cold applications, distraction, and decreasing environmental stimuli), and monitor for side effects of pain medications. The care plan dated 04/18/19 revealed the resident was started on Trazodone at night due to reports of difficulty sleeping with interventions to monitor for drowsiness during the day time, observe for side effects every shift, monitor for effectiveness of mediations and follow up with physician if she continues to report difficulty sleeping and precede or accompany medication use by other interventions to try to improve sleep such as consistent bed time routine, offer bed pan during night time care, offer a snack, and promote a calm quiet environment. There were no documented evidence of non-pharmacological interventions attempted prior to PRN Trazodone and PRN Tramadol medication administrations in June 2021 or July 2021. The resident received PRN Tramadol 32 times in June 2021 and seven times in July 2021. The resident received PRN Trazodone 25 times in June 2021 and five times in July 2021. Review of the resident's gradual dose reduction, dated 08/06/20, revealed the pharmacist recommended the physician consider a gradual dose reduction for the scheduled Trazodone 50 mg at night. On 08/11/20 the physician ordered to continue Trazodone 50 mg PRN for insomnia. On 08/25/20 the resident was started on Trazodone 50 mg PRN at night for insomnia. On 09/08/20 the medication regimen review revealed the resident had an as needed order for Trazodone and according to CMS guidelines, the medication could only be written for 14 days initially and it could be extended if the resident was evaluated by the physician and documentation could be provided with reasoning and with a specified time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 11 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete frame. It was recommended that the physician re-evaluate. The physician marked DISAGREE and stated She is using it almost every night. Interview on 07/08/21 at 11:37 A.M. and again at 3:05 P.M. with the Director of Nursing (DON) confirmed the absence of documentation of non-pharmacological interventions for the PRN Trazodone and PRN Tramadol and the absence of a rationale for the PRN Trazodone being extended past a 14 day order. Event ID: Facility ID: 366411 If continuation sheet Page 12 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, facility policy and procedure review, and specific medication web sites, the facility failed to ensure extended release (ER) medications were not crushed and administered to residents, resulting in a significant medication error. This affected one resident (#15) out of six residents reviewed during the medication administration observation. The census was 15. Residents Affected - Few Findings Include: Review of Resident #15's medical record revealed an admission date of 04/27/21 and the diagnoses of joint replacement surgery, fractured vertebrae, depression, cerebral infarction, gastro-esophageal reflux disease, and high blood pressure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two staff for bed mobility and extensive assistance of one staff for eating. Review of the physician orders revealed the resident was ordered Metoprolol Succinate ER 25 mg daily for high blood pressure and instructions to crush medications unless contraindicated. The care plan dated 07/06/21 revealed the resident had a swallowing problem related to swallowing assessment results with intervention for all staff to be informed of special dietary and safety needs. There was no documented evidence of why crushing her Metoprolol wouldn't adversely affect the resident. Observation on 07/07/21 at 8:20 A.M. with Licensed Practical Nurse (LPN) #121 revealed she was preparing medications for Resident #15. She placed all of the resident medications into the medication cup, including Metoprolol ER 25 mg, and she then crushed all of the medications to mix them in apple sauce. LPN #121 administered the medications at 8:34 A.M. When asked if the resident had an order to crush her medications she showed an order to crush medications unless contraindicated. At 8:51 A.M., LPN #121 confirmed an extended release tablet would be a contraindication to crushing medications. Review of the policy and procedure titled Crushing Medications, undated, revealed medications should only be crushed when it is appropriate and safe to do so, consistent with physician orders. It further stated staff should make the physician aware if there is an order to crush a drug that the manufacturer states should not be crushed (for example long acting or enteric coated medications). Review of the Metoprolol web site instructions revealed Metoprolol ER is a tablet with extended release technology, they contain Metoprolol Succinate in a multitude of controlled release pellets. Each pellet has a separate drug delivery unit and is designed to deliver Metoprolol continuously over the 24-hour period. It stated the tablet had a film coating for easier swallowing and that they should not be crushed or chewed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 13 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, the facility failed to ensure loose and expired medications were not available in the medication cart for the 200 hall residents. This had the potential to affect one resident (#5) who received Lasix and three residents (#9, #12, and #126) who received Tylenol on the 200 hall from the 200 hall medication cart. The census was 15. Findings Include: Observation and interview on 07/07/21 at 11:10 A.M. of the 200 hall medication cart with Licensed Practical Nurse (LPN) #121 revealed a white oval pill with the numbers 3169 (Lasix 20 mg) loose in the cart, Tylenol 325 mg that expired February 2021 and Benadryl 25 mg that expired April 2021. LPN #121 confirmed the loose medications and expired medications at that time. Interview on 07/08/21 at 3:33 P.M. with the Director of Nursing (DON) revealed three residents (#9, #12, and #126) were ordered over the counter Tylenol 325 mg, there were no residents with orders for Benadryl 25 mg, and Resident #5 was the only resident with Lasix 20 mg ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 14 of 15 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 366411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Robert A Barnes Center 2225 Taylor Park Drive Reynoldsburg, OH 43068 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy and procedure review, the facility failed to maintain infection control during medication administration. This affected one resident (#15) out of six residents observed during medication administration. The census was 15. Residents Affected - Few Findings Include: Review of Resident #15's medical record revealed an admission date of 04/27/21 and the diagnoses of joint replacement surgery, fractured vertebrae, depression, cerebral infarction, gastro-esophageal reflux disease, and high blood pressure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two staff for bed mobility and extensive assistance of one staff for eating. Review of the physician orders revealed the resident was ordered Doxycycline Hyclate 100 mg twice daily for left lung effusion for seven days. An observation and interview on 07/07/21 at 8:19 A.M. during medication administration revealed Licensed Practical Nurse (LPN) #121 preparing Resident #15's medications into the medication cup. She dropped the resident's Doxycylcine 100 mg on the medication cart, picked it up with her bare hands and placed it back in the medication cup. The surveyor intervened and LPN #121 confirmed she had touched the residents medications with her bare hands and that it was unsanitary. LPN #121 continued to pass the contaminated medication to the resident despite surveyor intervention, and it was administered at 8:34 A.M. At 8:51 A.M. she confirmed that she still administered the contaminated medication to the resident despite the surveyors attempted intervention. Review of the policy titled Administering Medications, undated, revealed staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications and treatments as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366411 If continuation sheet Page 15 of 15