Inspection visit

Health inspectionJanuary 9, 2023

GRAND THECMS #36643531 citations on this visit

31 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 31 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, review of the Resident [NAME] of Rights, and policy and procedure review, the facility failed to ensure privacy was maintained and residents were treated with dignity and respect during incontinence care. This affected one resident (#60) out of seven residents reviewed for pressure ulcers. The census was 84. Findings Include: Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. Diagnoses included dysphagia, adult failure to thrive, severe protein calorie malnutrition, chronic kidney disease stage four, anorexia, depression, pneumonia, shortness of breath, falls, malignant bladder cancer, and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition, and the resident required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive one staff assistance for personal hygiene and dressing and limited assistance of one staff for eating. It stated the resident was incontinent of bowel and bladder and he was at risk for pressure ulcers, but had no wounds. Review of the care plan dated 12/18/22 revealed Resident #60 had pressure related skin alterations and was at risk for pressure related injuries related to changes in skin and muscle mass, co-morbidities, history of pressure injuries and incontinence. It stated the resident required assistance with skin care and the resident had interventions to turn and reposition as needed and apply treatments per orders. Observation on 12/19/22 at 12:49 P.M. with State Tested Nurse Assistant (STNA) #176 revealed incontinence care and wound observation for Resident #60, with the door completely shut. While STNA #176 was in middle of patient care and while the resident was exposed, Licensed Practical Nurse (LPN) #224 walked into Resident #60's room without knocking. LPN #224 fully opened the door and dropped off the residents meal tray. Interview on 12/19/22 at 12:49 P.M. with LPN #224 (and with STNA #176 present) verified he had not knocked, the door was opened wide, and the staff were in the middle of patient care. He stated he had to drop off the residents meal tray and was unaware Resident #60 was in the middle of patient care when he walked in. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 79 Event ID: 366435 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility policy and procedure titled Resident Privacy: Education and Training, dated 02/18/22 revealed staff will be trained on resident privacy regarding knocking and receiving permission to enter rooms. It stated staff will enter a residents room once permission is granted by the resident. Review of the Resident [NAME] of Rights, undated revealed residents have the right to be treated with courtesy and respect and full recognition of dignity and individuality. It also stated the residents have the right to privacy during medical examinations and personal care. This deficiency revealed non-compliance contained in allegations in Complaint Number OH00138037, OH00137957, and OH00135966. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 2 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and review of the resident fund documentation, the facility failed to obtain authorization to manage funds and maintain witnessed authorizations for residents. This affected four residents (#17, #19, #32, and #37) out of five residents reviewed for funds. The facility census was 84. Residents Affected - Some Findings include: 1. Review of the personal fund authorization revealed Resident #19's representative authorized the facility to manage funds, however, it was undated and there was no witness. 2. Review of the personal fund authorization revealed Resident #37's representative authorized the facility to manage funds on 06/02/21, this was unwitnessed. 3. Review of the personal fund authorization revealed Resident #17 wanted to manager her own funds, this was signed by her representative on 10/16/18 and was unwitnessed. Review of the trust transaction history for Resident #17 revealed the facility was managing her funds. 4. Review of the personal fund authorization revealed Resident #32 authorized the facility to manage her funds on 12/19/22, however, it was unwitnessed. Review of the resident fund account balance list revealed Resident #19, Resident #37, Resident #17, and Resident #32 had funds managed by the facility. Interview on 12/28/22 at 4:07 P.M., with the Administrator verified Resident #37 and Resident #32's authorization was unwitnessed. She said Resident #19's was undated and unwitnessed. The Administrator verified Resident #17 had not approved the facility to authorize her funds, she reported this was an error and a new authorization would be obtained, she verified the original authorization was not witnessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 3 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff and family interview, the facility failed to ensure the resident representatives and the physician were notified of falls. This affected two residents (#25 and #76) out of seven residents reviewed for falls. The facility census was 84. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive impairment. The resident required the extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Resident #76 had one fall with injury. Review of Resident #76's medical record revealed he had family as his responsible party. Review of the progress note dated 11/18/22 at 8:11 A.M. revealed the STNA was in the lobby with the resident when he slid on the floor. Review of the fall investigation dated 11/18/22 revealed Resident #76 was in the recliner and slid out on the floor. Review of the medical record revealed no evidence the physician or family representative was notified of the fall. Interview on 12/18/22 at 5:05 P.M., with Resident #76's representative revealed she did not think the facility was notifying her of every change. Interview on 12/20/22 at 11:13 A.M., and 2:22 P.M., with the Director of Nursing (DON) verified there was no evidence the physician or family were notified of Resident #76's fall. 2. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, mood disorder, pain in right wrist, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the progress note dated 11/23/22 revealed the nurse was approached by Resident #25's daughter with a concern that she was reporting extreme back pain with movement. The daughter stated she was informed by a staff member that her mother had fallen a few days ago. Review of the medical record revealed no additional information related to a fall prior to 11/23/22 or any physician or family notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 4 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 A follow-up interview on 12/21/22 at 2:21 P.M., the DON verified there was no documentation related to Resident #25's fall or family and physician notification. 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: 366435 If continuation sheet Page 5 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all relevant mental disorders were listed on the resident Preadmission Screening and Resident Review (PASARR). This affected one resident (#76) out of two residents reviewed for PASARR. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment. Resident #76 required extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Review of the physician's note dated 08/23/22 revealed Resident #76's diagnoses included mood disorder. Review of the Certified Nurse Practitioner's (CNP) note dated 08/25/22 revealed Resident #76's diagnoses included mood disorder. Review of the PASARR Identification screen dated 08/19/22, revealed Resident #76 had no mental disorders including mood disorder. Interview on 12/20/22 at 2:22 P.M., with the Director of Nursing (DON) verified mood disorder was identified as a diagnosis by the physician and the CNP but was not on Resident #76's PASSAR. The DON said this was the most recent PASSAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 6 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident baseline care plans were completed upon admission to the facility. This affected two residents (#28 and #42) out of 26 residents reviewed for care plans. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and a history of falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mild impaired cognition and required extensive assistance from two staff members for bed mobility, transfers, and toilet use. Further record review for Resident #28 revealed no evidence a baseline care plan was completed. 2. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder recurrent with psychotic symptoms, hemiplegia and hemiparalysis following cerebral infarction, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, hypertension, contracture of the right hand, schizoaffective disorder, constipation, atrial fibrillation, restless leg syndrome, unspecified psychosis, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had moderate impaired cognition. The resident required supervision for transfers and bed mobility and extensive assistance from one staff member for toilet use and eating. Further record review for Resident #42 revealed no evidence a baseline care plan was completed. Interview with the Director of Nursing on 12/27/22 at 3:45 P.M., verified there was not a baseline care plan available for Resident #28 and #42. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 7 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans reflected the resident assessments. This affected three residents (#28, #40, and #42) out of 26 residents reviewed for care planning. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. The resident was at risk for the development of pressure ulcers. Review of the comprehensive care plan for Resident #28 revealed no evidence of a care plan addressing the risk for the development of pressure ulcers. Interview with the Director of Nursing (DON) on 12/20/22 at 11:10 A.M., verified there was not a care plan for Resident #28 addressing the risk for pressure ulcer development. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] and had diagnoses including muscle weakness, asthma, retention of urine, depression, dementia, unspecified protein-calorie malnutrition, anemia, hypertension, age related osteoporosis, and altered mental status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 had moderate impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and extensive assistance from one staff member for eating. Review of the comprehensive care plan for Resident #40 revealed there was no evidence of a care plan addressing the need for assistance with Activities of Daily Living (ADL's) until 12/27/22, during the annual survey review. Interview with the DON on 12/27/22 at 3:45 P.M., verified the care plan addressing the need for assistance with ADL's was not initiated for Resident #40 until 12/27/22, during the annual survey review. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder recurrent with psychotic symptoms, hemiplegia and hemiparalysis following cerebral infarction, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, hypertension, contracture of the right hand, schizoaffective disorder, constipation, atrial fibrillation, restless leg syndrome, unspecified psychosis, and Alzheimer's disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 8 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had moderate impaired cognition. The resident required supervision for transfers and bed mobility and required extensive assistance from one staff member for toilet use and eating. Resident #42 had functional impairment on one side of the upper extremity. Review of the comprehensive care plan for Resident #42 revealed there was no evidence of a care plan addressing a right hand contracture, limited range of motion, or the need for assistance with ADL's. Interview with the Director of Nursing on 12/20/22 at 11:10 A.M. verified there was not a care plan for Resident #42 addressing a right hand contracture, limited range of motion, or the need for assistance with ADL's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 9 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure timely review and revision of care planned interventions. This affected one resident (#19) out of seven residents reviewed for falls. The facility census was 84. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and had diagnoses including age related osteoporosis, hemiplegia and hemiparalysis, weakness, need for assistance with personal care, diabetes mellitus, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had mild impaired cognition. The resident was dependent upon two staff members for transfers, bed mobility, and toilet use. Resident #19 had one fall with injury since the previous assessment. Review of the most recently revised care plan dated 11/30/22, revealed Resident #19 had a history of falls with injuries and was at risk for further injuries related to falls. Interventions included a fall mat to the left side of the bed and a mat on the floor to the right side of the bed. Observation on 12/19/22 at 10:58 A.M., revealed the right side of Resident #19's bed was positioned directly against the wall in the room and a fall mat was observed to the left side of the bed. Observation on 12/27/22 at 9:50 A.M. revealed the right side of Resident #19's bed was positioned directly against the wall in the room. A fall mat was observed on the left side of the bed on the floor. Interview with Licensed Practical Nurse (LPN) #222 on 12/28/22 at 2:35 P.M., verified the right side of Resident #19's bed was placed directly against the wall and there was no space to put a floor mat on the right side of the bed, only the left side. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 10 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Closed medical record review revealed Resident #87 was admitted to the facility on [DATE] and discharged on 09/16/22. Diagnoses included peripheral neuropathy, urinary tract infection, osteoarthritis of the hip, muscle weakness, insomnia, hyperlipidemia, hypothyroidism, anxiety, hypertension, protein-calorie malnutrition, basal-cell carcinoma, protein-calorie malnutrition, and gastro-esophageal reflux disease. Residents Affected - Some Review of the MDS assessment dated [DATE] revealed Resident #87 was alert and oriented to person, place, and time and able to make his needs known. The resident was dependent on one staff for bathing. Review of the shower documentation revealed Resident #87 had received a shower/bath on 09/11/22 and 09/14/22 during her stay at the facility. No other documentation was provided by the facility of Resident #87's bathing services. Interview with the Director of Nursing on 12/27/22 at 1:05 P.M., verified the facility could not provide further evidence of Resident #87's bathing services while at the facility. The DON verified Resident #87 had only two bed baths or showers over a span of seventeen days in the facility. This deficiency represents non-compliance related to allegations in Complaint Numbers OH00138037, OH00137957, and OH00135966. Based on medical record review, observation, staff, resident, and family interview, review of the hospice documentation, and policy and procedure review, the facility failed to ensure dependent residents received assistance with daily care. This affected one resident (#60) reviewed for oral care, three residents (#25, #76 and #87) reviewed for showers, one resident (#42) reviewed for shaving, and one resident (#28) reviewed for meals out of seven residents reviewed residents reviewed for activities of daily living. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. Diagnoses included dysphagia, adult failure to thrive, severe protein calorie malnutrition, chronic kidney disease stage four, anorexia, depression, pneumonia, shortness of breath, falls, unsteadiness on feet, muscle weakness, benign prostatic hyperplasia, malignant bladder cancer, and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition, and the resident required extensive assistance of two staff for bed mobility, transfers, and toilet use, extensive one staff assistance for personal hygiene and dressing and limited assistance of one staff for eating. The assessment documented the resident had coughing or choking during meals, he had a mechanically altered diet and he had weight loss. Review of Resident #60's Speech Therapy (ST) notes revealed on 06/29/22 the resident had a swallow evaluation completed and the ST recommended oral care three times daily. Review of the care plan dated 06/28/22 revealed Resident #60 had an activities of daily living (ADL) Self Care Performance Deficit and was at risk for a decline in ADL self performance and associated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 11 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some complications related to limited mobility and the use of assistive devices and weakness with interventions for staff assistance with personal hygiene and oral care. Review of Resident #60's oral care and meal intake documentation revealed the resident only received oral care assistance once to twice daily, though he was eating three meals per day, and on 12/20/22, he only received oral dental care in the evening, though he ate three meals that day. Interview on 12/19/22 at 12:46 P.M., Resident #60 revealed staff had not assisted him to brush his teeth regularly and he would like it at least once daily. Interview on 12/19/22 01:50 P.M., with Resident #60's family member revealed he didn't think staff were brushing Resident #60's teeth before the meals as per therapy recommendations. Interview on 12/20/22 at 2:02 P.M., with Dietician #300 revealed she spoke to Resident #60's family about Speech Therapy recommendations and the importance of following them and they verbalized understanding. She stated if ST was the one recommending the oral care three times daily, they should have put an order in, however, the Dietician #300 verified oral care was not documented as completed three times daily in the tasks. Observation and interview on 12/20/22 at 1:14 P.M. with Resident #60 revealed he was eating his lunch. The resident stated he had not had his teeth brushed at all this day. Interview on 12/20/22 at 1:17 P.M., the State Tested Nurse Assistant (STNA) #176 verified she had not completed oral care on Resident #60 yet today, breakfast or lunch. She stated they would document electronically when it was completed. Review of the facility policy and procedure titled Teeth Brushing, dated 04/16/13 revealed residents should be assisted with brushing their teeth based on their individual needs. 2. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. Review of the care plan dated 03/07/22 with a current revision dated 11/23/22 revealed Resident #28 had a self care deficit and, upon return from hospital on [DATE], the resident would need assistance of care times two team members. Interventions included the resident would need assistance from two team members for all Activities of Daily Living (ADL's), check and change every two hours with two team members, the resident required set up assistance with meals, cut up and then cueing, and two staff members in the room for all care. Review of the active physicians order dated 11/11/22 revealed an order for Resident #28 to be assisted/fed for all meals. Review of the nutritional care plan revised 12/15/22 revealed Resident #28 had a nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 12 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some problem or was at nutritional risk. Upon return from the hospital on [DATE] was dependent on staff for eating and needed fed. Observation and interviews on 12/18/22 at 10:05 A.M. revealed Resident #28 was observed slumped to the left side while sitting up in the bed and was asleep. The residents breakfast meal tray was observed on the over the bed table in front of the resident. There were small pieces of bacon observed on the residents stomach and in the residents bed. The remainder of the breakfast meal remained untouched on the residents tray. Resident #28 stated staff members brought in the meal trays then left the room and had not provided any assistance. At 10:12 A.M., State Tested Nursing Assistant (STNA) #228 entered the room and assisted Resident #28 to sit up in the bed. STNA #228 stated she was unaware Resident #28 required any assistance consuming meals. Observation on 12/18/22 at 2:00 P.M. revealed Licensed Practical Nurse (LPN) #222 took the lunch meal tray into the room of Resident #28, set up the meal tray, then exited the room leaving no staff member in the room to assist the resident with consuming the meal. Observation on 12/19/22 at 11:15 A.M. revealed Resident #28 was observed lying in bed sleeping. The residents breakfast meal tray was located on the over the bed table in front of the resident. The residents bacon was not on the tray and pieces of bacon were observed on the resident and in the residents bed. A bowl of soggy cold cereal with milk and a cinnamon roll were observed untouched on the residents tray. Observation on 12/21/22 at 2:05 P.M. revealed Resident #28 was sitting up in bed attempting to consume the lunch meal. Resident #28 was observed having difficulty getting food items into her mouth and was dropping food on the table, herself, and the bed. No staff members were observed in the room. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder recurrent with psychotic symptoms, hemiplegia and hemiparalysis following cerebral infarction, chronic obstructive pulmonary disease, dysphagia, unspecified mood disorder, unspecified protein-calorie malnutrition, dementia without behavioral disturbance, hypertension, contracture of the right hand, schizoaffective disorder, constipation, atrial fibrillation, restless leg syndrome, unspecified psychosis, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had moderate impaired cognition. The resident required supervision for transfers and bed mobility and to require limited assistance from one staff member for personal hygiene, Review of the active care plans for Resident #42 revealed no care plan was available addressing ADL's. Observation on 12/19/22 at 10:44 A.M. revealed Resident #42 was sitting in a wheelchair in the dining area. The residents beard hair was long and needed shaved. The residents right hand was severely contracted. Observation and interview on 12/20/22 at 11:25 A.M. revealed Resident #42 was sitting in his wheelchair in his room. The residents beard hair was long and needed grooming. Resident #42 said he wanted shaved but could not complete the task himself due to his right hand contracture. Observation and interview with STNA #126 on 12/20/22 at 11:29 A.M. revealed residents should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 13 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some shaved on their shower days and as needed. The STNA #126 verified Resident #42 appeared unshaved and the length of the hair growth looked like over a week since he was shaved. STNA #126 verified Resident #42 was unable to shave himself and needed staff assistance. 4. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, unspecified severe protein-calorie malnutrition, alcohol abuse, major depression. Review of Resident #76's quarterly MDS assessment dated [DATE] revealed he had a severe cognitive impairment. The resident required physical help of one person in part of bathing. Review of the plan of care dated 09/09/22 revealed Resident #76 had an actual or limited physical mobility related to history of falls, dementia, and severe protein calorie malnutrition. Interventions included hands on assistance with activities of daily living, monitor the resident's ability to perform in mobility activities, and observing for and reporting to the physician signs of immobility. Review of Resident #76's documented showers dated from 11/19/22 to 12/18/22 revealed the resident received a bed bath on 11/20/22, 11/25/22, 11/26/22, 12/8/22, 12/09/22, and 12/15/22. The resident was missing showers on 12/13/22, 12/06/22, 12/02/22, 11/28/22, and 11/20/22. Review of the shower schedule revealed Resident #76 should have received showers on Tuesdays and Fridays. Observation on 12/18/22 and 12/19/22 revealed Resident #76 had combed back greasy hair. Interview on 12/19/22 at 12:50 A.M., with State Tested Nursing Aide (STNA) #187 revealed Resident #76 should be showered on Tuesdays and Fridays and required staff assistance with this task. She reported showers were not always able to be completed due to insufficient staffing. Review of the policy titled Bathing and showering, dated December 2006 revealed assistance with showering and bathing was to be provided two times a week and as needed. 5. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, unspecified mood disorder, pain in right wrist, and unspecified osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Resident #25 required the physical help of one person with bathing. Review of the plan of care dated 05/10/21 revealed Resident #25 had an activity of daily living self-care performance deficit related to impaired mobility, weakness and deconditioning. Interventions included conversing with the resident while providing care, monitoring and reporting any changes to the nurse, promoting dignity by ensuring privacy, and hands on assistance for bathing, bed mobility, dressing, eating, transfers, and toilet use. Review of the hospice aide's documentation revealed on 12/08/22 Resident #25 had not received a bath because the task was already completed, on 12/14/22 Resident #25 received a bed bath, and on 12/19/22 a bed bath was not required. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 14 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #25's facility documented showers from 11/19/22 to 12/18/22 revealed she received a shower on 11/26/22 and a bed bath on 12/14/22. Interview on 12/19/22 at 11:26 A.M., with Resident #25's family revealed there was some confusion on whether the facility or hospice was supposed to provide her bathing. Resident #25's family revealed an aide had reported hospice completed the residents baths now and he was worried she might not be getting them. Interview on 12/20/22 at 8:15 A.M., with STNA #187 revealed Resident #25's bathing schedule was changed after discussion with hospice to Monday and Wednesday. She reported bathing for Resident #25 was joint between the facility and hospice, however, bathing was not always able to be completed due to insufficient staffing. Interview on 12/21/22 at 11:50 A.M., with the Director of Nursing (DON) revealed she thought Resident #25 refused showers often, however, she verified the documentation had not indicated Resident #25 refused showers. Review of the policy titled Bathing and showering, dated December 2006 revealed assistance with showering and bathing was to be provided two times a week and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 15 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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** 3. Review of the medical record for Resident #13 revealed an admission date of 11/16/22 and the diagnoses of Parkinson's disease, depression, cramps and spasms, high blood pressure, muscle weakness, muscle contracture's, and reduced mobility. Residents Affected - Some Review of the admission MDS assessment dated [DATE] revealed Resident #13 had a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition and she required extensive assistance of two staff for transfers and bed mobility and she required total dependence of one staff for locomotion via wheelchair. The assessment documented it was very important to her to attend her favorite activities, though no activity preferences were documented. Review of Resident #13's care plan dated 11/21/22 revealed the resident was to reside at the facility in long term placement with interventions to encourage participation in activities of choice. The care plan dated 12/06/22 revealed the resident had an activities of daily living (ADL) self care performance deficit and was at risk for a decline in ADL self-performance and associated complications related to Parkinson Disease, bilateral lower extremity contracture's and contracture of upper extremity for which she wears braces. Interventions included encourage the resident to participate to the fullest extent possible with each interaction and the resident was dependent on staff for daily care with bed mobility, transferring and mobility. Review of Resident #13's activity log for December 2022 revealed from 12/01/22 through 12/18/22, Resident #13 only attended one Bingo activity out of 15 opportunities. Review of the December 2022 Activity Calendar provided (but was dated December 2021) revealed on 12/19/22 Bingo was at 10:00 A.M., and on 12/20/22 and 12/21/22 Bingo was at 11:00 A.M. Observation and interview on 12/19/22 at 11:04 A.M. Resident #13 was in bed doing a word search. She stated that was the activity for the day. She stated no one invited her to bingo this morning and she really likes bingo. Interview on 12/20/22 at 8:03 A.M., with Activities Director #154 revealed Resident #13 likes Bingo, among other activities. She stated if the resident was up and wanted to go to activities, then she goes. Interview on 12/21/22 at 9:19 A.M., with Activities Assistant #182 revealed he was conducting Bingo on this date at 11:00 A.M. he stated he notified the residents every morning of the activities and they used calendars, then the residents tell them if they want to go or not. He stated Resident #13 would go to activities if they get her out of bed, and if they dont get her up, she wont go. He stated activities staff would ask the aides to get her up for the activities, but they dont always listen. He further revealed Resident #13 likes activities and would come often if the aides would get her up. Observation on 12/21/22 at 11:03 A.M. revealed the Bingo activity was going on in the activities center, Resident #13 was not present. A follow-up observation and interview on 12/21/22 at 11:05 A.M. with Resident #13 revealed she wanted to go to Bingo and they had not invited her to Bingo today. The resident was in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 16 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 - Some Interview on 12/21/22 at 11:39 A.M. with State Tested Nurse Assistant (STNA) #219 revealed the aide staff ask residents when they were getting them ready if they want to go to activities. She stated she didn't ask Resident #13 if she wanted to go to Bingo on this day. She also stated she had not seen activities staff today so they never told her Resident #13 wanted to go to the Bingo activity. Observation and interview on 12/21/22 at 2:07 P.M. with STNA #219 and Activities Assistant #182 revealed Resident #13 up in her wheelchair. The Activity Assistant stated it would increase her quality of life if she could go to activities regularly. The Activity Assistant walked up to Resident #13 and asked if she would like to go to the Moving and Music activity and the resident stated yes with a smile on her face. Based on medical record review, observation, staff and resident interview, and review of the facility activity calendar, the facility failed to ensure activities were available to residents in isolation for COVID-19 infection, ensure group activities were available to residents, and to ensure assistance to activities was provided for residents who were unable to attend activities independently. This directly affected three residents (#13, #21, and #36) out of 26 residents reviewed for activities during the annual survey with the potential to affect 23 additional residents (#02, #08, #09, #11, #13, #15, #17, #19, #20, #26, #28, #31, #35, #40, #41, #42, #46, #49, #50, #55, #59, #64, and #69) who resided on the B unit. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses including heart failure, hypertension, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. The resident required extensive assistance from one staff member for bed mobility, transfers, and toilet use. Review of the facility Resident Daily Activity Participation dated 12/2022 documented Resident #21 had not participated in or been offered any activities from 12/09/22 through 12/18/22. Interview with Resident #21 on 12/27/22 at 12:54 P.M., revealed the resident was not offered any individual activities while in isolation due to an infection with COVID-19. Resident #21 stated the only time staff came in her room was to administer medications, pass meal trays, and answer her call light. The resident stated she had participated in several activities prior to being in isolation. Interview with the Activities Employee #182 on 12/27/22 at 1:46 P.M., revealed the facility activity staff did not offer or provide residents on isolation for COVID-19 infection activities until their isolation was discontinued. 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] and had diagnoses including heart failure, hypertension, and respiratory failure. Review of the annual MDS assessment dated [DATE] revealed Resident #36 had intact cognition. The resident required extensive assistance from one staff member for bed mobility, transfers, and toilet use. Review of the facility Resident Daily Activity Participation dated 12/2022 documented Resident #36 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 17 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 had not participated in or been offered any group activities from 12/08/22 through 12/19/22. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #36 on 12/18/22 at 10:10 A.M., revealed the resident was upset because group activities were not being provided due to other residents in the facility having COVID-19. The resident stated she had been very active in group activities prior and was hoping they would start back soon. Residents Affected - Some Interview with Activities Employee #182 on 12/27/22 at 1:46 P.M. revealed group activities for all residents residing on the B unit of the facility had been stopped when the first resident tested positive for COVID-19 on 12/08/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 18 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview, review of the facility investigations, and policy and procedure review, the facility failed to ensure Resident #44's wound was monitored routinely and the dressing was changed as ordered, failed to ensure Resident #62's wound cause was comprehensively investigated and the wound dressing was changed as ordered, failed to ensure Resident #189 had an order for a wound dressing, failed to ensure appropriate positioning for Resident #19, and failed to ensure Resident #28 had geri-sleeves on as ordered. This affected five residents (#19, #28, #44, #62, and #189) out of 22 residents reviewed for quality of care. The facility identified 23 residents with non-pressure skin impairment. The facility census was 84. Residents Affected - Some Findings Include: 1. Review of the medical record for Resident #44 revealed an admission date of 10/14/22 and 11/23/22 with diagnoses of malignant neoplasm of bladder, diabetes type two, liver cirrhosis, muscle weakness, need for assistance with personal care, unsteadiness on feet, hydronephrosis with renal and urethral calculous obstruction, pain in left hip, metabolic encephalopathy, nephrostomy catheter displacement, chronic kidney disease stage four. Review of the five day minimum data set (MDS) assessment dated [DATE] revealed Resident #44 had intact cognition and required extensive one staff assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. The assessment documented the resident was at risk for pressure, he had a surgical wound, but no other wounds and no pressure ulcers. Review of the care plan dated 10/21/22 revealed Resident #44 was at risk for pressure related skin alteration injuries related to changes in skin and muscle mass, co-morbidities, diabetes, general debilitation, reduced bed mobility, and requiring assistance with skin care with interventions for weekly visual skin checks, and maintain preventative interventions. Review of the physician orders revealed orders to cleanse the left knee with normal saline, pat dry, apply a foam dressing and change Mondays, Wednesdays, Fridays and as needed, initiated 12/18/22. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2022 and December 2022 revealed no documented evidence of a treatment being completed for Resident #44's left knee prior to 12/18/22. The knee dressing on the TAR, dated 12/19/22 (Monday), was signed off as completed. Review of Resident #44's fall investigations revealed the following: On 11/26/22, the nurse observed that the residents call light was on, upon checking on him, the resident was noted kneeling on the floor in front of his chair with no underwear/pants on, he was soiled with feces. He stated he had finished going to the bathroom and was trying to put on his underwear when he slipped and fell. The resident stated he crawled on his knees to the chair. A head to toe assessment was completed, a small abrasion was noted to his knees, he complained of pain to knees and legs, range of motion was within normal limits, he denied hitting his head when asked, and he was alert and oriented per baseline. He was assisted off the floor with three staff assistance to his bed and pericare was provided. As needed pain medication was administered and neurological checks were initiated. The physician and family were aware. On 11/28/22 the STNA informed the nurse that the resident was down on his knees in his room. The nurse found the resident facing the head of his bed on the left side, trying to use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 19 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the chair as leverage to get up. The resident was actively trying to get his legs under him so that he had enough strength to pull himself from the floor, using the back of the chair. The resident was unable to do this so the nurse and aide assisted the resident with a gait belt. When nurse asked the resident what happened, he responded that he was trying to get something off of his bedside table. The resident denied hitting his head or any pain or discomfort. A head to toe skin assessment was completed and noted bilateral abrasions on knees actively bleeding. The bilateral knee abrasions were cleaned and bandages were applied. Neurological checks were initiated and the physician and his family were notified of the fall and the abrasions. Observation on 12/18/22 at 12:08 P.M. revealed Resident #44 with a dressing to his left knee dated 12/18/22. Observation on 12/21/22 at 8:17 A.M. with Licensed Practical Nurse (LPN) #140 revealed Resident #44's left knee dressing was dated 12/18/22, though it was due to be changed 12/19/22 (Monday). The dressing was soiled at the top but intact. LPN #140 also confirmed the TAR was signed off in error. Interview on 12/21/22 2:26 P.M., with the Director of Nursing (DON) verified there was no wound monitoring for Resident #44's knee wound, besides 11/26/22 when it was found. 2. Review of the medical record for Resident #62 revealed an admission date of 10/14/22 and the diagnoses of fractured right femur, severe protein calorie malnutrition, muscle weakness, high blood pressure, malignant neoplasm of right breast, and atrial fibrillation. Review of the admission MDS assessment dated [DATE] revealed Resident #62 had intact cognition and the resident required extensive two staff assistance for bed mobility, transfers, toilet use and personal hygiene, and supervision for eating. The resident was at risk for pressure ulcers, had a pressure ulcer and a surgical wound. Review of the care plan dated 10/21/22 revealed Resident #62 had pressure related skin alteration injury and/or is at risk/potential risk for pressure related skin alteration injury related to anemia, changes in skin and muscle mass, co-morbidities, general debilitation, immobility, incontinence, reduced bed mobility, requires assistance with skin care, weight loss history and a skin tear from 12/13/22. Interventions included weekly visual skin checks and administer treatments as ordered. Review of the physician orders for Resident #62 revealed orders to cleanse the right lower extremity skin tear with normal saline and pat dry, apply foam dressing and change every Monday, Wednesday and Friday and as needed. Review of the TAR for December 2022 revealed the residents dressing was documented as completed on 12/14/22 and 12/16/22. Review of the investigation dated 12/13/22, revealed the nurse was called into Resident #62's room by an aide to report a bruise, the assessment found a 5.0 centimeter (cm) by 2.5 cm by 0.1 cm deep skin tear to the right lower extremity. Both the aide and resident did not know how the skin tear happened but the resident was noted with fragile skin. Wound care orders were obtained to cleanse with normal saline, pat dry, apply foam dressing to right lower extremity, Mondays, Wednesdays, Fridays and as needed. The residents family and physician were notified. Interview on 12/20/22 at 11:13 A.M., with the Director of Nursing (DON) revealed she had just spoken with Resident #62's daughter about the incident from 12/13/22. The daughter stated she noticed the resident scratching at her lower legs earlier that day and she was sure this was what caused the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 20 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm area to her lower leg. The DON verified there was no additional information in regard to their investigation into the wound and that she had just initially spoke to the daughter on this day. Observation on 12/19/22 at 1:10 P.M. of Resident #62 revealed a dressing applied to her right ankle dated 12/13/22. Residents Affected - Some Observation and interview on 12/19/22 at 1:37 P.M. with Licensed Practical Nurse (LPN) #108 verified Resident #62's right ankle dressing was dated 12/13/22. LPN #108 said the dressing was inaccurately signed as completed in the TAR on 12/14/22 and 12/16/22. 3. Review of the medical record for Resident #189 revealed an admission date of 12/13/22 and the diagnoses of encounter for orthopedic aftercare, malignant prostate cancer, hormone resistant malignancy, anemia, and high blood pressure. Review of the admission MDS assessment dated [DATE] revealed Resident #189 had a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident was at risk for pressure, he had no pressure ulcers, but did have a surgical wound and a skin tear. Review of the skin assessment dated [DATE] revealed Resident #189 had a skin tear and a surgical incision. The skin tear was to the back of the right hand measuring 0.8 cm by 1.0 cm by 0.1 cm deep. The left hip had two surgical incision, 13 staples noted to the superior incision and 12 staples noted to the inferior incision. The assessment stated therahoney and border gauze were ordered as a treatment but it does not specify which treatment the order was for. Review of the physician orders dated 12/14/22 revealed orders for surgical incision care to cleanse the left hip/thigh surgical incision with normal saline, pat dry, apply border gauze daily and as needed if soiled and dislodged. On 12/18/22, the physician ordered to cleanse the back of the right hand with normal saline, pat dry, apply therahoney Gel/sheet to the wound bed and cover with a clean dry dressing every Monday, Wednesday, Friday and as needed if soiled and dislodged. Prior to 12/18/22, there was no evidence of a physician order/completed treatments to the residents right hand wound. Review of Resident #189's baseline care plan dated 12/13/22 revealed the resident had actual skin alterations with interventions to follow skin care protocols and provide treatments as ordered. Observation and interview on 12/18/22 at 11:30 A.M. with Resident #189 revealed a soiled dressing to his right hand dated 12/14/22. Resident #189 stated he scraped his hand when he fell at home prior to coming to the facility. Interview on 12/18/22 at 11:52 AM with Registered Nurse (RN) #183 verified Resident #189 had an undated/initiated soiled hand wound dressing and the absence of an order for Resident #189's hand wound and documentation for any treatments to the residents right hand. RN #183 stated she thought the skin assessment orders for the therahoney was for the hand. Review of the facility policy and procedure titled Skin Care Program, dated 11/28/22 revealed upon admission and upon observation of a new skin issue, a resident will have their skin assessed from head to toe by a nurse, each area will be documented and the information will be entered into the electronic charting system. The physician will be notified for orders and representatives will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 21 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm notified accordingly. It stated a nurse will measure each skin issue weekly and update the plan of care as needed. The facilities policy was to manage the residents skin issues to avoid development unless unavoidable due to a residents condition. The policy stated the residents who are admitted to the resident with skin issues will receive the necessary care and treatments to promote healing and prevent infection or new skin issues from developing unless they are clinically unavoidable. Residents Affected - Some 4. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] and had diagnoses including age related osteoporosis, hemiplegia and paralysis, weakness, need for assistance with personal care, and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #19 had mild impaired cognition. The resident was dependent upon two staff members for toilet use, bed mobility, and transfers. Review of the active care plans for Resident #19 revealed no care plan or intervention related to positioning the resident with feet elevated while in the wheelchair. Further review of the residents medical record revealed no documentation of the need to position Resident #19 with feet elevated while in wheelchair. Observation on 12/18/22 at 1:00 P.M. revealed Resident #19 was in her room and was positioned in her wheelchair with the head of the wheelchair tilted back and feet elevated above the level of the residents body and was sleeping. Observation on 12/19/22 at 10:58 A.M. revealed Resident #19 was positioned in her wheelchair with head of the wheelchair tilted back and feet elevated above the level of the residents body while the resident was in the dining area on the unit. Observation on 12/27/22 at 9:50 A.M. revealed Resident #19 was in her room and was positioned in her wheelchair with the head of the wheelchair tilted back and feet elevated above the level of the residents body. Interview with Licensed Practical Nurse (LPN) #222 on 12/28/22 at 2:35 P.M., verified staff almost always positioned Resident #19 in her wheelchair with the head of the chair tilted far back and feet elevated above the level of the residents body. LPN #222 stated the resident may be positioned that way as a fall intervention or for comfort, but was unsure of the exact reason. 5. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition evidenced by a BIMS assessment score of 11. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. Review of the active physicians order revealed an order dated 10/21/22 for Geri-sleeves every shift for wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 22 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation and interview on 12/19/22 at 4:15 P.M. revealed Resident #28 was lying in bed and Geri-sleeves were not applied as ordered by the physician. State Tested Nursing Assistant (STNA) #126 verified Resident #28 did not have on Geri-sleeves and denied knowledge of the residents order for Geri-sleeves. Observation and interview on 12/21/22 at 10:55 A.M. revealed Resident #28 had no Geri-sleeves on as ordered by the physician. STNA #226 verified Resident #28 did not have on Geri-sleeves and denied knowledge of the residents order for Geri-sleeves. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 23 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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, observation, staff interview, the facility failed to ensure physician ordered pressure ulcer interventions were implemented. This affected one resident (#28) out of six residents reviewed for pressure ulcers. The facility census was 84. Residents Affected - Few Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and a history of falls. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #28 had mild impaired cognition. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and limited assistance from one staff member for eating. The resident was assessed at risk for development of pressure ulcers. Review of the active care plans for Resident #28 revealed there was no care plan related to pressure ulcer prevention. Review of the physicians order dated 07/28/22 revealed an order for Resident #28 to float heels when in bed and document refusals. An order dated 11/21/22 revealed to turn and reposition the resident every two hours and as needed. Review of the Treatment Administration Record (TAR) for 10/2022, 11/2022, and 12/2022 revealed no documentation of refused treatments or physicians orders. Observation and interview on 12/18/22 at 10:30 A.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress. The State Tested Nursing Assistant (STNA) #228 verified the residents legs and heels were not elevated/floated. Observation on 12/19/22 at 11:15 A.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated/floated. Observation on 12/19/22 at 1:30 P.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated/floated. Observation and interview on 12/19/22 at 4:15 P.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated/floated. STNA #126 verified the residents legs and heels were lying directly against the bed mattress and were not elevated/floated. STNA #126 stated there was not always enough staff to turn and reposition residents every two hours and denied knowledge of the last time Resident #28 had been turned or repositioned in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 24 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure timely follow-up of therapy recommendations to prevent the potential worsening of a residents contracture. This affected one resident (#42) out of two residents reviewed for range of motion. The facility census was 84. Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder recurrent with psychotic symptoms, hemiplegia and hemiparalysis following cerebral infarction, contracture of the right hand, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had moderate impaired cognition. The resident required supervision for transfers and bed mobility, extensive assistance from one staff member for toilet use and eating. The resident had a functional impairment on one side of the upper extremity. There was no restorative nursing services received. Review of the active care plans for Resident #42 revealed there was no care plan addressing contracture's or limited range of motion. Review of the active physicians orders for Resident #42 revealed no order related to contracture's, splints, or other devices. Review of the facility Occupational Therapy Discharge summary dated [DATE] revealed recommended Resident #42 for a splint/brace and assistance with Activities of Daily Living (ADL's). Discharge reason maximum potential reached, referred for Restorative Nursing Program (RNP). Observation on 12/18/22 at 1:28 P.M. revealed the right hand of Resident #42 was severely contracted with no splint or other devices in place. Observation on 12/19/22 at 10:44 A.M. revealed Resident #42 was sitting in the dining room in a wheelchair. The residents right hand was observed severely contracted with no splints or devices in place. Observation and interview with the Director of Therapy Services (DOTS) #500 on 12/20/22 at 10:36 A.M. revealed Resident #42 admitted to the facility with a contracture of the right hand and brought a splint with him. The DOTS #500 stated the residents' contracture did not appear to have worsened since the resident was admitted to the facility. A follow-up interview with the DOTS #500 on 12/20/22 at 10:55 A.M., verified the Occupational Discharge Therapy Summary dated 05/12/22 recommended a splint/brace and for the resident to be referred for the RNP which was supposed to be followed up by the nursing staff. Interview with the Director of Nursing on 12/20/22 at 11:10 A.M., verified there were no physicians order or care plans addressing the use of a splint or brace for Resident #42. The Director of Nursing also verified the facility did not have a RNP. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 25 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0688 Observation on 12/20/22 at 11:25 A.M. revealed Resident #42 was observed in his room with no splint or other device in place to his contracted right hand. 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: 366435 If continuation sheet Page 26 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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** 5. Review of the medical record for Resident #44 revealed an admission date of 10/14/22 and 11/23/22 with diagnoses including malignant neoplasm of the bladder, diabetes type two, liver cirrhosis, muscle weakness, need for assistance with personal care, unsteadiness on feet, and chronic kidney disease. Review of the five day MDS assessment dated [DATE] revealed Resident #44 had intact cognition and he required extensive one staff assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. Review of Resident #44's care plan dated 10/21/22 revealed the resident was at risk for falls related to deconditioning, requiring assistance with ambulation, required assistance with transfers, total/partial loss of balance while standing, and unsteady gait. Interventions included orthostatic blood pressures for 48 hours on 11/28/22 for possible hypotension, bed in the low position, offer toileting at night and twice through the night, and monitor vital signs as ordered. Review of the fall risk assessments for Resident #44, dated 11/14/22, 11/23/22, and 11/28/22, revealed he was at moderate risk for falls. Review of Resident #44's physician orders for November 2022 revealed order for orthostatic blood pressures of lying, sitting, and standing every shift for two days, initiated on 11/28/22. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2022 revealed only two documented blood pressures, one on 11/29/22 and one on 11/30/22. Review of Resident #44's fall investigations revealed the following: On 11/26/22, the nurse observed the residents call light was on, upon checking on him, the resident was noted kneeling on the floor in front of his chair with no underwear/pants on, he was soiled with feces. Feces was noted on the carpet and in his bathroom on the commode. He stated he had finished going to the bathroom and was trying to put on his underwear when he slipped and fell. The resident stated he crawled on his knees to the chair. A head to toe assessment was completed, a small abrasion was noted to his knees, he complained of pain to knees and legs, range of motion was within normal limits, he denied hitting his head when asked, and he was alert and oriented per his baseline. He was assisted off the floor with three staff assistance to his bed and pericare was provided. As needed pain medication was administered and neurological checks were initiated. A new intervention to offer toileting before bed and twice during the night was initiated. The physician and family were aware. On 11/28/22 the STNA informed the nurse that the resident was down on his knees in his room. The nurse found the resident facing the head of his bed on the left side, trying to use the chair as leverage to get up. The resident was actively trying to get his legs under him so that he had enough strength to pull himself from the floor, using the back of the chair. The resident was unable to do this so the nurse and aide assisted the resident with a gait belt. When the nurse asked the resident what happened, he responded that he was trying to get something off of his bedside table. The resident denied hitting his head or any pain or discomfort. A head to toe skin assessment was completed and noted bilateral abrasions on knees actively bleeding. The bilateral knee abrasions were cleaned and bandages were applied. Neurological checks were initiated and the physician and his family were notified of the fall and abrasions. physician and family notified. Review of the nurses notes dated 11/28/22 at 4:12 P.M. revealed the physician notified the nurse of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 27 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 new orders for orthostatic blood pressures of lying, sitting, and standing every shift for two days. Resident #44 was notified of the new orders. There was no documented evidence of the results of the orthostatic blood pressures in the nurses notes. Interview on 12/20/22 at 12:45 P.M., with the DON verified there were no root cause analysis determinations for the 11/28/22 fall. At 3:50 P.M., the DON verified there was no documentation of what Resident #44's orthostatic blood pressures were. 6. Review of the medical record for Resident #62 revealed an admission date of 10/14/22 and the diagnoses of fractured right femur, severe protein calorie malnutrition, muscle weakness, high blood pressure, malignant neoplasm of right breast, and atrial fibrillation. Review of the admission MDS assessment dated [DATE] revealed Resident #62 had intact cognition and the resident required extensive two staff assistance for bed mobility, transfers, toilet use and personal hygiene, and supervision for eating. Review of the fall risk assessment for Resident #62 dated 11/07/22 revealed the resident was a high risk for falls. Review of the care plan for Resident #62 dated 10/21/22 revealed the resident was at risk/or potential risk for falls related to history of fall related injury, incontinence, medication use, poor safety awareness, unsteady gait and requires assistance with transfers. Interventions included bed in lowest position when in bed and check the placement every shift. Review of the care plan dated 10/21/22 revealed the resident had an activities of daily living (ADL) self care performance deficit and was at risk for decline in ADL self-performance and associated complications related to impaired balance, limited mobility, limited range of motion, pain, requires assist to perform/complete ADL care, self-performance varies, and weakness with interventions to ensure hands on assistance by staff for bed mobility and transfers. Observation on 12/18/22 at 10:22 A.M. of Resident #62 revealed her bed was elevated and not in the lowest position. Observation and interview on 12/18/22 at 10:48 A.M., with Registered Nurse (RN) #168 verified Resident #62's bed was not in the lowest position, she promptly lowered the bed. Review of the facility policy and procedure titled Accident/Incident-Prevention/Fall Risk, dated 07/31/14 revealed the nursing staff are responsible for assessing a residents fall risk and implementing proactive interventions as well as new interventions should an incident or accident occur. Based on medical record review, observation, staff and family interview, review of electronic communication, review of the fall investigations, review of the incident log, review of the education sheet, review of the hospital records, and policy review, the facility failed to ensure fall interventions were in place to prevent falls. This resulted in Actual Harm for Resident #76 when he had a fall, was sent to the hospital and suffered an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the fourth proximal phalanx base (ring finger) as well as an age indeterminate fracture of the fifth metacarpal base (small finger) and a laceration to the head requiring a suture. In addition, the facility failed to ensure fall interventions were implemented, fall investigations were thorough, and the fall root cause analysis was identified. This affected six residents (#05, #25, #38, #44, #62, and #76) out seven residents reviewed for falls. The facility census was 84. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 28 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Findings include: Level of Harm - Actual harm 1. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, severe protein-calorie malnutrition, alcohol abuse, and major depression. Residents Affected - Few Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment. The resident required the extensive assistance of staff for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, and toilet use. Resident #76 had one fall with injury. Review of the plan of care dated 11/07/22 and 12/07/22 revealed Resident #76 was at risk for falls and had a safety awareness deficit related to a history of falls. Fall interventions were added as follows: on 09/04/22 send to the emergency room, on 09/10/22 offer snacks or beverages between meals, on 09/15/22 use gripper socks, on 09/16/22 dycem in the wheelchair, on 09/23/22 dycem on the top and the bottom of the cushion in the wheelchair, on 10/04/22 encourage nonskid shoes, on 10/30/22 one-to-one observation and send to the emergency room, on 11/02/22 therapy and physician evaluation, on 11/05/22 one-to-one observation, send to emergency room, scheduled toileting, hipsters, bed in the lowest position, a fall mat, 15-minute checks, and a medication review, on 11/16/22 assisting to the recliner following dinner, on 11/18/22 dycem to the recliner, on 11/22/22 place the resident in the recliner when out of the bed and out of the room with dycem, on 12/03/22 a Velcro cushion to the chair, and a physical therapy evaluation, and on 12/06/22 staff education on safety precautions. Additional interventions included anticipating and meeting needs and evaluate for unsteady gait. Review of Resident #76's physician's orders revealed an order dated 08/20/22 for non-skid footwear when out of bed. An order dated 09/23/22 for dycem to the top and the bottom of the wheelchair cushion when in use. An order dated 11/07/22 for non-skid footwear or grippy socks, offer snacks and beverages between meals, to toilet before and after meals, upon rising, at bedtime, and twice at night, for hipsters on at all times except when doing care, the bed next to the wall, and for a fall mat to the left side of the bed. An order dated 12/03/22 revealed an order for a sheet of dycem to be applied under and over the cushion to prevent sliding. Review of the progress note dated 09/04/22 at 12:26 P.M. revealed Resident #76 was found on the bathroom floor lying on his right arm. Blood was noted on the floor next to his head and his third finger on his right hand was swollen and painful to the touch. Resident #76 was sent to the hospital for evaluation. Review of the fall investigation dated 09/04/22 revealed Resident #76 was found on the bathroom floor with only his socks on. He was not able to state how he had fallen; injuries were noted, and Resident #76 was sent to the hospital. Predisposing factors were that the bathroom recess was slippery and footwear. Review of the emergency room documentation dated 09/04/22 revealed Resident #76 had a laceration of the scalp and a closed fracture of his right hand. The radiographic imaging of his right hand during the visit revealed an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the 4th proximal phalanx base as well as an age indeterminate fracture of the fifth metacarpal base. Resident #76 received one suture to his head laceration. Interview on 12/18/22 at 4:54 P.M. with Resident #76's family revealed he was supposed to have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 29 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 dycem in his wheelchair to prevent falls, but it was not always present. Level of Harm - Actual harm Observation on 12/19/22 from 10:37 A.M. to 12:49 P.M. revealed Resident #76 was in his wheelchair. At 12:49 P.M. State Tested Nursing Aide (STNA) #187 assisted Resident #76 to a standing position revealing a pressure reducing cushion in his chair. There was dycem above the cushion, however, there was no dycem present under the cushion. STNA #187 confirmed this observation and reported she thought another resident had the dycem. Residents Affected - Few Interview on 12/20/22 at 10:34 A.M., with STNA #187 revealed Resident #76 required assistance with dressing and undressing including footwear. STNA #187 reported Resident #76 was unable to identify the next step in dressing and undressing. Interview on 12/20/22 at 11:13 A.M., with the Director of Nursing (DON) verified Resident #76 had an intervention of non-skid footwear prior to his 09/04/22 fall that was not in place. Review of the progress note dated 09/15/22 at 10:32 A.M. revealed the nurse was informed by the laundry personnel Resident #76 was on the floor. The resident was found in his room on the floor in front of his wheelchair. Resident #76 did not have on shoes and was wearing only socks. Review of the fall investigation dated 09/15/22 revealed immediate action taken included an assessment revealed a small skin tear to his left elbow, no other concerns were noted. Predisposing factors were identified as improper footwear, gait imbalance, ambulation without assistance, lack of safety awareness, and recent falls. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified Resident #76 had a previous intervention of non-skid footwear which was not in place at the time of his 09/15/22 fall. Review of the progress note dated 10/04/22 at 11:30 A.M. revealed Resident #76 was in his wheelchair in the hallway, he went to stand and fell landing on his left side. He was assessed with no concerns and reported he was bored. Therapy was to evaluate the resident for seating and his shoes were assessed. Resident #76 was noted to have slippers on and not shoes with traction. Review of the fall investigation dated 10/04/22 indicated predisposing factors as poor lighting, improper footwear, impaired memory, gait imbalance, easy agitation, lack of safety awareness, recent falls, poor judgement, and ambulating without assistance. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified Resident #76 had a previous intervention of non-skid footwear which was not in place at the time of his 10/04/22 fall. Review of the progress note dated 10/30/22 at 2:49 P.M. revealed Resident #76 fell in the common area and hit his head, the resident was noted with a cut to his forehead and abrasion to the right upper corner of his top lip. Resident #76 was sent to the hospital. Review of the fall investigation dated 10/30/22 revealed Resident #76 was found on the floor after a loud noise was heard. Resident #76 was last seen in the dining room eating lunch. He was noted with injuries to his face. Predisposing factors included confusion, forgetfulness, gait disturbance, and a history of falls. A follow-up interview on 12/20/22 at 11:13 A.M., with the DON verified the situation surrounding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 30 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Resident #76's 10/30/22 fall was not clearly identified or illustrated in the fall investigation, additionally, it was unclear if fall interventions were in place at the time of his fall. The DON was unable to provide additional information regarding the fall. Review of the progress note dated 11/22/22 revealed Resident #76 slid out of his wheelchair at 1:40 A.M. with no injuries. There was no documentation that dycem in his wheelchair was in place. Review of the progress note dated 12/03/22 at 5:00 A.M. revealed Resident #76 was sitting on the floor with the wheelchair behind him. He was assessed with no concerns noted and returned to his wheelchair, dycem to his wheelchair was recommended. Review of the fall investigation dated 12/03/22 revealed dycem to the wheelchair was recommended as well as Velcro to the cushion. Predisposing factors included impaired memory, gait imbalance, incontinence, recent falls, and an overestimation of ability. Neurological checks were initiated A follow-up interview on 12/20/22 at 11:13 A.M., and at 2:22 P.M., with the DON verified dycem should have been in place according to the 09/23/22 physician's order. The DON was unable to find completed neurological checks for the 12/03/22 fall. Review of the progress note dated 12/06/22 at 7:26 P.M. revealed Resident #76 was observed in a neighbor's bathroom on the floor with his wheelchair near the bed while his head faced the toilet. No injuries were noted, and the immediate intervention was staff education on safety precautions. Review of the fall investigation dated 12/06/22 revealed Resident #76 was assessed, and staff were educated. Predisposing factors included confusion, recent falls, ambulating without assistance, and overestimation of ability. A follow-up interview on 12/28/22 at 1:12 P.M., with the DON revealed staff were educated on the 12/06/22 fall because he was in his wheelchair and should have been in the recliner, which was a previous fall intervention. Review of the education sheet dated 12/06/22 revealed two staff were educated on safety precautions related to resident falls. Electronic communication on 12/29/22 at 12:14 P.M., with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individual's needs. 2. Review of the medical record for Resident #38 revealed an admission date of 07/02/22 with diagnoses including Parkinson's disease, unspecified convulsions, dysphagia, liver disease, hypertension, protein-calorie malnutrition, depression, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had severely impaired cognition. The resident required the extensive assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 31 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 plan of care dated 12/13/22 revealed Resident #38 was at risk for falls related to history of falls. Fall interventions were added as follows: on 10/05/22 a room evaluation with a wider path made to ensure safety, on 11/01/22 the emergency room, on 11/02/22 was a Spanish visual aide, on 11/14/22 the bed in the lowest position, on 11/18/22 ensuring non-skid footwear when out of bed, on 11/26/22 offer snacks between meals, on 11/28/22 offering morning showers was unsuccessful and changed to 15-minute checks for two days, on 12/10/22 one hour checks for 72 hours, on 12/11/22 dycem above and below the cushion in the wheelchair. Additional interventions included anticipating meeting resident needs, call light in reach, and provide safe environment. Review of Resident #38's physician's orders revealed an order dated 07/02/22 for nonskid footwear when out of bed, an order dated 11/14/22 for the bed in the lowest position, and an order dated 11/18/22 for nonskid footwear when out of the bed. Review of the progress note dated 11/18/22 at 1:30 P.M. revealed Resident #38 was found on the bedroom floor next to the door. Her slippers were half on and half off her feet and her walker was in close range. The resident stated the floor was slippery. A new order to use nonslip socks when out of bed and check placement was added. Review of the fall investigation dated 11/18/22 revealed the predisposing factors were listed as footwear, impaired memory, confusion, gait imbalance, and recent falls. Interview on 12/21/22 at 11:50 A.M., with the DON verified Resident #38 did not have nonskid footwear in place and this was an intervention initiated prior to the fall. Review of the progress note dated 11/26/22 at 4:19 P.M. revealed Resident #38 had just finished eating lunch and was asked to go to the living room with the other residents. Resident #38 refused and began hitting the nurse who stepped away to give her space. The aide spotted the resident wandering around the kitchen area and asked the resident to come with her and the resident refused hitting her as well. The aide proceeded to help another resident to the bathroom, when both staff heard a loud boom. The staff ran to the dining area and noticed the resident laying on the floor next to a chair by the kitchen window. Resident #38 reported she was standing on the chair and fell. Review of the fall investigation dated 11/26/22 revealed the fall investigation additionally reported an injury to the back of the head. Predisposing factors included forgetfulness, gait imbalance, recent falls, ambulating without assistance, and wandering. Review of the progress note dated 11/27/22 revealed Resident #38 had a recent fall and was noted to have a bruise to the forehead. A follow-up interview on 12/21/22 at 11:50 A.M., with the DON revealed she would not have left the resident alone, however, she was unwilling to speak on what the staff should have done. The DON noted the discrepancy between the descriptions of the injury related to the 11/26/22 fall. She reported she believed the problem was related to how the program used for fall investigations works. The DON reported she believed the nurse applied ice to a hematoma but had been unable to get a hold of the nurse to clarify. Review of the fall investigation dated 11/28/22 revealed the nurse heard a loud noise when standing by Resident #38's room. The nurse found the resident lying on her back her head resting on wall and her feet facing the shower. She was assessed and assisted to bed. There were no predisposing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 32 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 factors listed. Level of Harm - Actual harm A follow-up interview on 12/21/22 at 11:50 A.M. with the DON revealed she was unable to find additional information regarding whether fall interventions were in place at the time of the fall and additional details surrounding Resident #38's fall. Residents Affected - Few Review of the progress note dated 12/10/22 at 8:40 A.M. revealed Resident #38 was found by the nurse with an open cut on the forehead and side of head, there was blood on her pillow. Resident #38 was drowsy and emergency services were contacted. Review of the fall investigation dated 12/10/22 revealed Resident #38 revealed a fall intervention was put in place for one hour checks. A follow-up interview on 12/20/22 at 4:37 P.M., with the DON verified there was no information in the 12/10/22 progress note and fall investigation indicating Resident #38 fell. Further interview on 12/21/22 at 11:50 A.M. revealed the nurse who worked on 12/10/22 clarified the fall investigation and she would provide it. Review of the fall investigation dated 12/10/22 provided on 12/21/22 at 4:29 P.M. revealed a clarification had been made indicating blood was noted on the resident floor in front of the bathroom door. The Resident had been observed one hour prior by an STNA when she was resting quietly in her bed without injury. Review of the progress note dated 12/11/22 at 7:40 P.M. revealed the aide found Resident #38 on the floor by the wall after hearing a bang. The aide asked the resident to sit after noticing she was unstable and the resident refused. Review of the fall investigation dated 12/11/22 at 7:40 P.M. revealed Resident #38 was found on the floor by the wall after hearing a bang. The aide had asked the resident to sit after noticing she was unstable and the resident refused. The resident was sent to the emergency room for evaluation due to injury to the back of the head. No predisposing factors were indicated. A follow-up interview on 12/20/22 at 4:37 P.M., and 12/21/22 at 11:50 A.M., the DON verified the fall investigation had not explained the details of the fall including where it occurred and if fall interventions were in place at the time of the fall. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individual's needs. 3. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, mood disorder, pain in right wrist, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 33 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 plan of care dated 11/28/22 revealed Resident #25 was at risk for falls. Fall interventions were added as follows: on 05/12/22 staff assistance getting into bed, on 05/13/22 send to the emergency room, on 09/13/22 encourage use of the walker, on 09/18/22 send to the emergency room, on 11/25/22 send to the emergency room and dycem in the wheelchair, and on 11/26/22 change the wheelchair seat. Additional interventions included anticipating and meeting resident needs, assisting with toilet needs, bed in the lowest position, ensuring appropriate footwear, and reviewing past falls to attempt to determine cause. Review of the progress note dated 11/23/22 revealed the nurse was approached by Resident #25's daughter with a concern that she was reporting extreme back pain with movement. The daughter stated she was informed by a staff member that her mother had fallen a few days ago. Review of the medical record revealed no additional information related to a fall prior to 11/23/22. Review of the incident log through August 2022 revealed no incidents for Resident #25 in the days leading up to 11/23/22. Interview on 12/21/22 at 2:21 P.M., with the Director of Nursing (DON) verified there was no documentation related to Resident #25's fall and no fall interventions. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been implemented. Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individuals needs. 4. Observation on 12/18/22 at 10:05 A.M., 11:35 A.M., 1:23 P.M. and 2:58 P.M. revealed Resident #05's bed was not in the lowest position. This was verified by STNA #187 on 12/18/22 at 1:23 P.M. who reported she did not know this was an intervention for Resident #05. Review of the medical record for Resident #05 revealed an admission date of 02/11/18 with diagnoses including dementia, repeated falls, anxiety disorder, cognitive communication deficit, and muscle wasting and atrophy. Review of the quarterly MDS assessment dated [DATE] revealed Resident #05 had severely impaired cognition. Review of the plan of care dated 11/14/22 revealed Resident #05 was at risk for falls related to cognitive impairment, confusion, history of repeated falls, poor comprehension, need for assistance, and medication use. Fall interventions were added as follows: on 12/22/21 assistance with transfers, on 11/14/22 bed in the lowest position and two staff for assistance with transfers at all times. Additional interventions included ensuring appropriate footwear, involve responsible party in treatment plan, monitor medication use for side effects, and orient resident to facility and environment. Electronic communication on 12/29/22 at 12:14 P.M. with the DON revealed falls and incidents were discussed in clinical meetings every morning but interdisciplinary team notes have not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 34 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 implemented. Level of Harm - Actual harm Review of the policy titled Accident and Incident Prevention and Fall Risk dated 07/31/14, revealed residents identified as a fall risk will have proactive interventions implemented. Interventions will be reviewed and updated as needed per the individuals needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 35 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and policy review, the facility failed to ensure residents received timely physician ordered incontinence care and timely treatment was implemented for a resident with a urinary tract infection (UTI). This affected two residents (#16 and #28) out of five residents reviewed for bowel and bladder incontinence and UTI. The facility census was 84. Findings include: 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, and muscle weakness. Review of the care plan dated 03/07/22 revealed Resident #28 had incontinence episodes and/or was at risk for bladder incontinence. Occasionally incontinent. Interventions included to notify nursing if incontinent during activities, check and record bowel movement status every shift, and document and report to nurse any change in voiding pattern. Review of the care plan dated 03/07/22 and recently revised on 11/23/22 revealed Resident #28 had a self care deficit. Upon the return from the hospital Resident #28 would need assistance with care with two team members and check and change every two hours. Interventions included to check and change every two hours with two team members two staff members in room for all care, and required hands on assistance with bed mobility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had moderate impaired cognition. Resident #28 required extensive assistance from two staff members for toilet use and was always incontinent of bowel and bladder. Review of the active physicians order dated 11/21/22 revealed an order to toilet Resident #28 every two hours. Observation and interview on 12/18/22 at 10:30 A.M. revealed Resident #28 was lying in bed and had urinated and was in need of being changed. State Tested Nursing Assistant (STNA) #228 was present in the room and verified Resident #28 had urinated and needed changed and Resident #28 was unable to toilet herself. STNA #228 said Resident #28 was not provided incontinence care since the beginning of the shift at 7:00 A.M., which was three and half hours prior. STNA #228 stated there was not enough staff present to provide incontinence care every two hours. Observation on 12/21/22 at 10:55 A.M. revealed STNA #226 provided incontinence care to Resident #28. The resident's groin, inner thighs, peri-area, and buttocks were observed severely excoriated and deep red in color. While cleansing the resident's peri-area and groin, Resident #28 began yelling that hurts while grimacing and tensing up. Resident #28 asked STNA #226 why it was hurting and STNA #226 said it always hurts like this when we cleaned you because you are raw. Interview with STNA #219 on 12/21/22 at 11:58 A.M., revealed there was not sufficient staffing levels present in the facility to provide incontinence care every two hours. STNA #219 stated many residents on her assignment only had incontinence care provided once during the shift which had started at 7:00 A.M., five hours earlier. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 36 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0690 Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Practical Nurse (LPN) #222 on 12/21/22 at 2:10 P.M. verified staff were unable to provide incontinence care every two hours due to not having sufficient staffing levels. 2. Review of the medical record for Resident #16 revealed an admission dated of 04/09/21 with diagnoses including vascular dementia and cerebral infarction with hemiplegia and hemiparesis. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Review of Resident #16's physician's order dated 11/13/22 revealed an order for blood work and a urinary analysis one time only until 11/14/22. An additional order was written for 11/16/22 through 11/19/22 for blood work and urinary analysis to be drawn and collected on one of these selected dates with results to be sent to the physician's services. Another order dated 11/23/22 for a urinary analysis to be collected on that day with the results sent to the physician's service. Review of the progress note dated 11/15/22 revealed Resident #16 was not eating meals even with assistance. Resident #16 was taking two bites of each meal and drinking very little. The Certified Nurse Practitioner (CNP) was notified with new orders for blood work and a urinary analysis on 11/16/22. Review of the laboratory results collected and reported on 11/16/22 revealed the urine specimen was not collected. There were no urine specimens collected from 11/16/22 to 11/21/22. Review of the progress note dated 11/22/22 revealed a new order for a urinary analysis, the urine was collected on that date and an order was placed for the urine to be picked up on 11/23/22. Review of the laboratory results collected on 11/23/22 and reported on 11/25/22 revealed the urine culture revealed organisms growing. The physician or CNP had not responded to the urine culture results until five days later on 11/29/22. Review of the progress note dated 11/29/22 revealed the urinary analysis results were sent to the CNP, there were new orders for Macrobid (antibiotic medication) 100 milligrams (mg) twice a day for seven days. Interview on 12/21/22 at 2:21 P.M., with the Director of Nursing (DON) verified Resident #16's urinary analysis was not collected and reported in a timely manner. A follow-up interview on 12/28/22 at 11:02 A.M. revealed the labs were managed by the Assistant Director of Nursing (ADON). The ADON would keep track of the orders and upload the results in the electronic medical record. The DON reported the labs did not automatically go into the electronic medical record and the nursing staff would need to look up to see if results were in. She reported the gap in reviewing the results could have been because it was an agency staff. Review of the policy titled Lab Policy and Procedure, dated 10/10/13 revealed results should be reviewed from the vendor and abnormal labs should be reported to the physician. This deficiency represents non-compliance investigated under Complaint Numbers OH00137957, OH00135966, and OH00135623. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 37 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] and 12/02/22. Diagnoses included acute and chronic respiratory failure, tracheostomy, protein-calorie malnutrition, acute embolism and thrombosis, supplemental oxygen, encephalopathy, convulsions, depression, hypertension, atherosclerosis, congestive heart failure, glaucoma, cerebral infarction, gastro-esophageal reflux disease, dysphagia, aphagia, muscle weakness, frontal lobe deficits, and lethargy. Residents Affected - Some Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #71 was rarely/never understood. Review of the current physician orders dated 12/02/22 revealed Resident #71 currently received nothing by mouth, including food and medications. The resident received Jevity 1.5 continuous at 45 milliliter (ml) per hour via the g-tube. The resident was ordered weekly weights times four on admission, then monthly, if gain/loss over five percent in one month or 10 percent in 6 months notify the physician. Review of the weekly weights revealed on 12/02/22 Resident #71 weighed 183 pounds; on 12/09/22 weighed 177 pounds; and on 12/20/22 weighed 167 pounds. No other resident weights were provided. Interview with the Registered Dietician #300 on 12/20/22 at 12:30 P.M., verified Resident #71 should have weekly weights through the month of December following her most recent admission orders. Verified the resident has not had a documented weight since 12/09/22 per the weight logs. Registered Dietician (RD) #300 verified weights should have been completed at least every week. Review of the facility policy and procedure titled Weight Management Protocols, dated 04/16/21 revealed it is the facilities policy that all residents will be weighed upon admission and monthly thereafter unless more frequent monitoring is ordered by the physician or requested by nursing judgement or clinical nutrition assessment. Routine weight monitoring is a preventative care measure used in assessing a residents risk of malnutrition, functional decline, disease severely, or other associated adverse outcomes. 6. Review of the medical record for Resident #62 revealed an admission date of 10/14/22. Diagnoses included fractured right femur, severe protein calorie malnutrition, muscle weakness, high blood pressure, malignant neoplasm of right breast, and atrial fibrillation. Review of the admission MDS assessment dated [DATE] revealed Resident #62 had intact cognition and the resident required extensive two staff assistance for bed mobility, transfers, toilet use and personal hygiene, and supervision for eating. The assessment documented the resident was on a therapeutic diet and had weight loss. Review of Resident #62's weekly weights revealed on 12/02/22 the resident weighed 78.6 pounds and on 12/20/22 the resident weighed 89 pounds. There was no documented evidence of weekly weights completed between those dates. Review of the Real Food First - Personalized Meal Plan for Resident #62 dated 11/25/22 revealed the resident was to receive yogurt with breakfast and cottage cheese with lunch. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 38 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the physician orders for Resident #62 revealed orders for frozen nutritional treat twice daily with lunch and dinner for nutritional support, regular diet, regular texture, thin liquid consistency, assist to feed resident at all meals and cut up meats, Real Food First Program, and Remeron 15 mg at night for appetite. Review of the care plan for Resident #62 dated 10/19/22 revealed the resident was at risk for malnutrition and dehydration related to fracture of right femur, acute respiratory failure, severe protein-calorie malnutrition, acute ischemic heart disease, malignant neoplasm of overlapping sites of right female breast, a-fib, osteoporosis, hypothyroidism, iron deficiency anemia, high blood pressure, falls, weight loss, supplement use, fluid restrictions, psychotropic medication use, skin alterations, increased metabolic requirements and refusing ensure pudding/ensure plus. Interventions included assess/evaluate meal weights and meal intake trends as available and make recommendations as needed, assist resident with tray set up and/or meals as needed, cater to residents known food preferences as able, include resident and/or responsible party in treatment plan and update regarding change in status/treatment plan, obtain weights per orders, provide diet per physician orders, and supplements/vitamins/minerals/nutritional supplements as ordered. Review of the care plan dated 10/21/22 revealed the resident had an activities of daily living (ADL) self care performance deficit and associated complications related to impaired balance, limited mobility, limited range of motion, pain, requires assistance to perform/complete ADL care, self-performance varies, use of assistive devises, and weakness with an intervention, dated 10/21/22, that the residents is able to feed self, requires tray set up assistance only. Review of the Dietary Note dated 11/11/22 revealed on 10/16/22, Resident #62 weighed 94.8 pounds and on 11/10/22 the resident weighed 80.6 pounds (14.2 pound weight loss), indicating an underweight BMI of 15.2 kg/m2. A reweigh verified the weight loss. Review of the Dietary Note dated 11/19/22 revealed there was a conversation with Resident #62's family about the resident being tired in between bites and sips. The family would like for the resident to receive more assistance during meals, meats should be cut-up and more cueing and encouraging. The concerns were forwarded to appropriate parties. Review of the Dietary Note dated 12/12/22 revealed a meeting was held on 12/07/22 for Resident #62. The resident had a significant weight loss in November 2022, she was receiving Remeron for appetite stimulant, she required weekly weights, she was receiving a frozen nutritional supplement daily and is on the Real Food First Program and the resident required assistance with feeding at all meals. Observation on 12/19/22 at 1:16 P.M. of Resident #62 revealed she was served two baked chicken breast and they were not cut up. Resident observed cutting them up herself and eating/feeding herself. Observation on 12/20/22 at 1:32 P.M. of Resident #62 revealed she was served lunch which consisted of two hot dogs on buns and there was no no frozen nutritional treat on the tray or cottage cheese. The resident attempted to cut her own hot dogs and was feeding herself. Interview on 12/20/22 at 1:42 P.M. with Social Services #302 verified Resident #62 hasn't been assisted with her meal. He also verified the resident received two hotdog's not cut up, and no nutritional supplement. Interview on 12/20/22 at 1:45 PM with the STNA #219 verified Resident #62 was eating without assistance, she stated the resident didn't need any assistance and she liked to do it herself. She also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 39 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm stated the resident wants to cut her own meat but she did verify the absence of a nutritional supplement with her meal. Interview on 12/20/22 at 1:47 P.M. with LPN #264 revealed dietary provides the nutritional supplements with the tray. Residents Affected - Some Interview on 12/20/22 at 2:19 P.M. with Dietician #300 revealed in November 2022, Resident #62 triggered for significant weight loss, the resident stated she had a poor appetite and her Remeron medication was increased. She stated the resident was also on a Real Food First (RFF) program where she was suppose to receive cottage cheese at lunch time. Dietician #300 confirmed the resident had orders for weekly weights that were not completed and that the resident required feeding assistance at all meals, though she had never observed her eating before. Interview on 12/20/22 at 3:27 P.M. with the Corporate Dietician #301 and Dietary Director #172 revealed they were just figuring out how to document the RFF Program and how it should be on the residents meal tickets, she stated currently it wasn't but it will be on 12/21/22. She stated they would just keep each residents personal RFF Care plan in each kitchenette. Observation and interview on 12/20/22 at 3:33 P.M. with the Dietary Director #172, of the kitchenette where Resident #62 was served out of, revealed no RFF care plan for Resident #62. Dietary Director #172 verified there was no RFF Care Plan in the kitchenette for Resident #62, and the resident had not received the cottage cheese for lunch. Observation on 12/21/22 at 9:34 A.M. revealed Resident #62 eating by herself with no assistance. Interview on 12/21/22 at 9:59 A.M. with the STNA #219 verified the resident had not received assistance with eating breakfast, she stated the resident wanted to do it herself. Review of the facility policy and procedure titled Food and Nutrition Services, dated 11/20/17 revealed each resident shall receive and the facility will provide food that is prepared in a form designed to meet the individual needs of the resident. Review of the facility policy and procedure titled Nutrition Supplements, dated 08/19/14 revealed a physician order will be obtained for the use of a nutritional supplement. The use of a supplement designed to complement the meal will be provided by the dietary staff during the meal service. It stated nursing staff will supervise the delivery and consumption of the supplement. Review of the facility policy and procedure titled Weight Management Protocols, dated 04/16/21 revealed it is the facilities policy that all residents will be weighed upon admission and monthly thereafter unless more frequent monitoring is ordered by the physician or requested by nursing judgement or clinical nutrition assessment. Routine weight monitoring is a preventative care measure used in assessing a residents risk of malnutrition, functional decline, disease severely, or other associated adverse outcomes. This deficiency represents non-compliance discovered in Complaint Numbers OH00138037, OH00137957 and OH00135623. 3. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] and had diagnoses including infection with COVID-19, chronic obstructive pulmonary disease, type two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 40 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 diabetes mellitus, dysphagia, and gastrostomy malfunction. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment dated [DATE] revealed Resident #31 had intact cognition evidenced by a BIMS assessment score of 14. The resident required extensive assistance from one staff member for eating. Resident #31 was 59 inches tall and weighed 92 pounds with a weight loss of five percent or more in the last month or ten percent or more in the last six months while not on a prescribed weight loss regimen. The resident had a feeding tube, on a mechanically altered diet, and received 51 percent or more of the total calories through the tube feeding. Residents Affected - Some Review of the care plan revised on 11/23/22 revealed Resident #31 was at risk for malnutrition and dehydration. Interventions included to assess/evaluate meal intakes trends as available and make recommendations as needed, assist resident with tray set up and/or meals as needed, cater to residents known food preferences as able, encourage meal intakes of at least 75 percent, honor food likes and dislikes, record amount of food consumed with each meal per center protocols, and tube feeding and flushes per physician orders. Review of the physicians order dated 08/21/21 revealed Resident #31 was prescribed a regular diet with thin liquids. Review of the physicians order dated 12/03/22 and discontinued on 12/20/22 revealed Resident #31 was ordered Vital AF 1.2 (a tube feeding solution) at a rate of 50 milliliters an hour every night from 8:00 P.M. through 10:00 A.M. Review of the Medication Administration Record (MAR) for 12/2022 revealed on 12/19/22 Resident #31's Vital AF was documented as not administered. Review of the meal intake documentation dated from 11/29/22 through 12/28/22 revealed on 12/08/22 Resident #31 had documentation of the tube feeding and nothing by mouth (NPO), on 12/17/22 the resident had documentation of the tube feeding or not applicable, and on 12/20/22 the resident was documented as being NPO or not applicable. Documentation of the amount of the meal consumed was only present for seven out of the 30 days reviewed. Observation on 12/19/22 at 1:11 P.M. revealed the lunch meal trays were served and Resident #31 had no lunch meal tray served. Interview with the STNA #109 on 12/19/22 at 1:39 P.M., verified Resident #31 had not received a meal tray due to being scared to eat and stated the resident received all nutrition through tube feedings. Interview with the Dietary Aide #144 on 12/19/22 at 1:42 P.M., revealed there was no meal ticket for Resident #31 and stated the resident only received nutrition through tube feedings. Interview on 12/19/22 at 2:55 P.M., with the Dietary Manger #172 and the Dietary Aide #144 revealed residents were provided meals based on the meal tickets printed by kitchen staff and verified the meal tickets for Resident #31, dated Monday 12/19/22 and Tuesday 12/20/22, contained notes which read Tube Feed/No Food. Dietary Aide #144 stated he had been working at the facility for approximately four months and had never made a meal tray for Resident #31 because he had been told not to. Observation and interview with Resident #31 on 12/20/22 at 8:50 A.M. revealed there was no tube (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 41 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm feeding solution being administered to the resident. Resident #31 stated the facility was out of the ordered tube feeding solution and none was administered the night before by the nurse. Interview with the Central Supply employee #186 on 12/20/22 at 9:15 A.M., verified the facility had run out of the Vital AF 1.2 and stated it was ordered on 12/19/22 and should arrive on 12/21/22. Residents Affected - Some Interview with the Licensed Practical Nurse (LPN) #192 on 12/20/22 at 9:20 A.M., verified Resident #31 had not received the ordered tube feeding throughout the night due to the facility not having it in stock. Interview with the Registered Dietitian #300 on 12/20/22 at 1:08 P.M., revealed Resident #31 was ordered a regular diet with thin liquids in addition to the tube feeding administration and should be offered all meals by staff with refusals documented. Registered Dietitian #300 stated she was unaware the resident was not being offered meals by the facility. Registered Dietitian #300 stated she was aware Resident #31 did not receive her tube feeding as ordered on 12/29/22. 4. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] and had diagnoses including muscle weakness, asthma, retention of urine, depression, dementia, unspecified protein-calorie malnutrition, anemia, hypertension, age related osteoporosis, and altered mental status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #40 had moderate impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 01. The resident required extensive assistance from two staff members for bed mobility, transfers, and toilet use and extensive assistance from one staff member for eating. The resident was 62 inches tall, weighed 107 pounds, and had a weight loss of five percent or more in the past month or 10 percent or more in the last six months while not on a prescribed weight loss regimen. This resident was assessed to receive hospice services. Review of the care plan dated 08/29/22 and revised 11/29/22 revealed Resident #40 had nutritional problems or was at risk for malnutrition. Interventions included to provide and serve diet as ordered, record amount of food consumed with each meal per center protocols, and assist with meals as needed. Telephone interview with the responsible party for Resident #40 on 12/18/22 at 12:17 P.M., revealed the residents family was concerned she was not receiving enough water or fluids due to always being extremely thirsty when family was visiting and never having fluids available in reach. Observation and interview on 12/18/22 at 12:53 P.M. revealed Resident #40 was sitting in her room in her wheelchair by the end of the bed. There was a cup with water located on the residents bedside table which was not in reach of the resident. Interview with STNA #228 at the time of the observation verified the water was not in reach of the resident and was warm. STNA #228 stated she was unsure how long the water cup had been sitting on the table. Observation on 12/19/22 at 10:55 A.M. revealed Resident #40 was sitting in her wheelchair in her room. There was not a cup or fluids observed in the room for the resident to consume. Observation on 12/20/22 at 10:05 A.M. revealed Resident #40 was sitting in her wheelchair in her room. There was not a cup or fluids observed in the room for the resident to consume. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 42 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 12/27/22 at 9:40 A.M. revealed Resident #40 was sitting in her wheelchair in the middle of her room. There was not a cup or fluids observed in the room for the resident to consume. Based on medical record review, observation, staff, resident, and responsible party interview, and policy review, the facility failed to ensure fluids were available and provided for residents #05 and #40 and the facility failed to provide nutritional interventions, monitor weight and intake, and provide tube feeding as ordered for Resident #05, #31, #60, #62, #71, and #76. This effected two residents (#05 and #40) out of six residents reviewed for hydration and six residents (#05, #31, #60, #62, #71, and #76) out of seven residents reviewed for nutrition. The facility census was 84. Findings include: 1. Review of the medical record for Resident #05 revealed an admission date of 02/11/18 with diagnoses including dementia, repeated falls, muscle wasting and atrophy, cognitive communication deficit, and constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 had severely impaired cognition. She was on a mechanically altered and therapeutic diet. Review of the plan of care dated 12/16/22 revealed Resident #05 had a nutritional problem or potential nutritional problem related to advanced age, dementia, depression, anxiety, variable intake, assistance and cueing for meals, and refusals for meals at times. The resident was at risk for weight fluctuation secondary to diuretic use and therapeutic diet. Interventions included divided plate, assessing and evaluating weight and meal intakes, encouraging meal intakes, assessing nutritional needs for skin, observing for signs of dehydration, and obtain weights as ordered. Review of Resident #05's weights revealed she weighed 185.8 pounds on 05/05/22, 175.0 pounds on 08/25/22, 175.2 pounds on 09/02/22, and 160.2 pounds on 12/07/22. This indicated a 15-pound weight loss in three months and 8.7% (percent) significant weight loss and a 25.6-pound weight in seven months and a 16% signifcant weight loss. There were no weights recorded for June 2022 and from 09/03/22 to 12/06/22. Review of the dietary progress note dated 10/28/22 revealed Resident #05's most recent weight was 175.2 pounds on 09/02/22. Her intake at meals ranged from 0-100% and she was receiving supplements. The dietitian had no recommendations. There was no dietary follow up from 10/29/22 to 12/15/22. Review of the dietary progress note dated 12/16/22 revealed Resident #05 weighed 160.3 pounds which was a significant weight loss over three months. The dietitian had spoken to nursing regarding weight loss and reported the weight loss was likely related to behaviors and fair to poor intake. Resident #05's diet was liberalized due to advanced age and to promote intake. Her intake ranged from 25-100% but was mostly 26-75% at meals. She was independent with eating with set up help and assistance at times. The resident was receiving Medpass four ounces twice a day and accepting it well, the dietitian recommended increasing it to eight ounces. She additionally recommended monitoring weight and intake. Review of Resident #05's physician order dated 12/16/22 revealed an order for Medpass eight ounces two times a day for nutrition support and an order dated 12/17/22 for weekly weights every Saturday. Review of the intake records from 10/01/22 to 10/31/22 revealed only 43 of 93 possible meals were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 43 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm documented, there was only one instance of intake above 75%. Review of intake records from 11/01/22 to 11/30/22 revealed only 18 of 90 possible meals were documented, there was no intake documented above 75%. Review of intake records from 12/01/22 to 12/27/22 revealed only 13 of 81 possible meals were documented, there were only three instances of intake above 75%. Residents Affected - Some Observation on 12/18/22 at 10:05 A.M., 11:35 A.M., and 4:25 P.M. of Resident #05 had no available fluids. Observation on 12/19/22 at 10:33 A.M., 11:14 A.M., 11:49 A.M., 12:22 P.M., and 12:53 P.M. revealed no fluids in Resident #05's room. Interview on 12/19/22 at 12:56 P.M., with Licensed Practical Nurse (LPN) #127 verified Resident #05 did not have any fluids. Interview on 12/21/22 at 10:13 A.M., with State Tested Nursing Aide (STNA) #187 verified Resident #05 could drink without assistance. Observation on 12/21/22 of the breakfast meal revealed Resident #05 received her tray at 9:09 A.M. Scheduler #199 provided set up assistance and left the room. Further observations at 9:20 A.M., 9:29 A.M. and 9:49 A.M. revealed Resident #05 was not eating. Observation at 10:13 A.M. revealed Resident #05 had consumed none of her meal. Interview on 12/21/22 at 10:13 A.M. with STNA #187 verified Resident #05 had not eaten her breakfast. STNA #187 reported Resident #05 often refused assistance and ate on average 25-50% of her meals, she reported Resident #05 did not consume more than 50% of her meals. Interview on 12/27/22 at 4:51 P.M. with Dietitian #300 revealed she was aware meal intake documentation could vary depending on the resident. She reported intake documentation would help to notice patterns and would be helpful to review. She had not seen Resident #05 eat. Interview on 12/28/22 at 9:08 A.M. and 11:27 A.M., with the Dietary Technician #102 revealed she sent weekly emails to management of missing and needed weights. She confirmed Resident #5's October 2022 and November 2022 weights were missing. While Resident #05's December 2022 was a weight loss. 2. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, unspecified severe protein-calorie malnutrition, alcohol abuse, major depression. Review of Resident #76's quarterly MDS assessment dated [DATE] revealed he had a severe cognitive impairment. He was on a mechanically altered and therapeutic diet. Review of Resident #76's physician's orders revealed an order dated 11/10/22 for a regular diet, an order dated 11/20/22 for frozen nutritional treat one time a day, an order dated 12/15/22 for Medpass eight ounces three times a day, and an order dated 12/24/22 for weekly weights on Fridays. Review of the plan of care dated 12/15/22 revealed Resident #76 had a nutritional problem or malnutrition risk related to advanced age and diagnoses. Interventions included assessing and evaluating weight and meal intake trends as available, assisting with meals as needed, encourage meal intakes, honoring preferences, recording amount of food consumed, and as of 11/09/22 the resident required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 44 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 total assistance at meals. Level of Harm - Minimal harm or potential for actual harm Review of Resident #76's weights revealed Resident #76 weighed 132.4 pounds on 08/22/22, 136.4 pounds on 09/01/22, 132.9 pounds on 10/10/22, 123.8 pounds on 11/02/22, 115 pounds on 12/12/22, and 112 pounds on 12/16/22. Residents Affected - Some Review of the dietary progress note dated 12/15/22 revealed Resident #76 weighed 115 pounds which was a significant weight loss over one and three months. The dietitian had spoken to nursing, and they reported weight loss was likely related to behaviors and his intake varied depending on the day. The resident's intake ranged from 0-100% but was mostly 51 to 100%. She recommended increasing Medpass, discontinuing liquid protein, and continuing the frozen nutritional treat. Review of the dietary technician's note dated 12/23/22 revealed Magic cup was on back order; the family and physician were notified and the resident was placed on the Real Food First Program. Review of Resident #76's intake records from 11/28/22 to 12/27/22 revealed intake was only documented or 16 of 90 possible meals. Interview on 12/27/22 at 9:51 A.M., with Dietary Director #172 reported the facility had been out of Magic Cups for two weeks due to them being not available from the supplier. Dietary Director #172 reported those on Magic cup should be getting ice cream or sherbet and that nursing had been informed. Interview on 12/27/22 at 4:51 P.M., with Dietitian #300 revealed she was aware meal intake documentation can vary depending on the resident. She reported intake documentation would help to notice patterns and would be helpful to review. Dietitian #300 reported she had not been informed they were out of the frozen nutritional treat until 12/23/22 and an intervention was put in place to make up for the out-of-stock supplement by Dietary Technician #102. Interview on 12/27/22 at 9:01 A.M., with Dietary Technician #102 revealed she was informed of the lack of frozen nutritional treats on 12/23/22. She reported she thought there were some lingering cups in some of the kitchenettes (there were five total) but she verified that did not mean everyone had been getting them if they weren't widely available. Review of the policy Weight Management Protocols, dated 05/29/15 revealed monthly weights were obtained on all residents at approximately the same time of month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 45 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of laryngeal cartilage, chronic pain syndrome, pulmonary embolism, acute embolism and thrombosis, and alcohol abuse. Residents Affected - Few Review of the quarterly MDS assessment dated [DATE] revealed Resident #18 was was alert to name only and unable to make his needs known. Review of current physician orders revealed Resident #18 was ordered Buprenorphrine patch 20 micrograms (mcg) per hour transdermal once a week for cancer related pain. The Medication was due on 12/10/22 per the Medication Administration Records, however, the medication was not available to apply on 12/10/22 date as it had not been received from the pharmacy. Review of the Controlled Drug Receipt revealed the medication was dispensed and delivered on 12/11/22. The patch was not applied until 12/14/22 per LPN #162, which was reflected on the nursing note on the same date. Review of the Nursing note from 12/14/22 revealed LPN #162 documented the pain patch placed today on the left upper arm due to it not being placed on Monday 12/12/22 when it was received from the Pharmacy. Interview with the LPN #162 on 12/20/22 at 10:55 A.M., verified that the patch was not placed after it was received from the pharmacy on 12/11/22. She verified she was off work when the patch came in, and when she returned on 12/14/22, she noticed it had not been administered while she was off work. Then verified she had placed the patch on Resident #18, and signed it off on the Controlled Medication Report. This deficiency represent non-compliance found in Complaint Number OH00135966. Based on medical record review, observation, staff, resident and family interview, review of the drug control sheet, and policy and procedure review, the facility failed to ensure pain was addressed, treated, and monitored appropriately after reports of pain for Residents #28 and #44, and failed to ensure pain medication was available and administered as ordered for Residents #18 and #25. Actual Harm occurred when Resident #28 experienced pain during incontinence care rated on a numeric pain scale as a nine out of 10 (zero being no pain and 10 being the worst pain), the State Tested Nurse Assistant (STNA) continued to provide the care without addressing or reporting the pain. Actual Harm also occurred when Resident #44 experience pain rated on a numeric pain scale as an eight out of 10, and upon follow-up the resident continued to complain of eight out of 10 pain and no new pain interventions were completed until approximately four hours after the pain follow-up. This affected four residents (#18, #25, #28, and #44) out of four residents reviewed for pain management. The census was 84. Findings Include: 1. Review of the medical record for Resident #44 revealed an admission date of 10/14/22 and 11/23/22 with diagnoses of malignant neoplasm of the bladder, diabetes type two, liver cirrhosis, muscle weakness, need for assistance with personal care, hydronephrosis with renal and urethral calculous (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 46 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 obstruction, pain in left hip, metabolic encephalopathy, and chronic kidney disease stage four. Level of Harm - Actual harm Review of the five day minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and he required extensive one staff assistance for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. It documented he had a surgical wound. Residents Affected - Few Review of the care plan dated 12/29/22 revealed Resident #44 was at risk for pain related to chronic pain, pain evaluations, malignant neoplasm of the bladder, diabetes, and liver cirrhosis with interventions to attempt to eliminate and/or reduce causative factors of pain, administer pain medication as ordered and monitor effectiveness, and observe for non-verbal pain. Prior to 12/19/22, there was no pain specific care plan for Resident #44. Review of Resident #44's pain assessment dated [DATE] revealed he has frequent pain daily at an intensity of 7/10, he can complain of pain vocally, and the resident had as needed pain medication ordered. Review of Resident #44's physician orders for December 2022 revealed orders for Oxycodone five mg with instructions to give 15 mg every four hours as needed for pain (initiated 12/16/22). Review of the Medication Administration Record (MAR) revealed on 12/21/22 at 10:01 A.M. the Oxycodone was administered for a pain rating of eight out of 10. Upon reassessment, the medication was ineffective and at 4:22 P.M. the Oxycodone was administered again for a pain rating eight out of 10. Upon reassessment, the medication was effective. Review of the nurses notes dated 12/21/22 at 10:01 A.M. revealed Resident #44 was in eight out of 10 pain to his left hip so Oxycodone 15 mg was administered. at 12:34 P.M. the residents pain was reassessed and it was documented that the pain medication was ineffective and he was still at an eight out of 10 on the pain scale. At 4:22 P.M. the Oxycodone 15 mg was administered again for eight out of 10 pain to his left hip. At 6:10 P.M. the residents pain was reassessed and it was documented the resident also received an ice pack and the interventions were effective. Interview on 12/21/22 at 4:08 P.M. with Licensed Practical Nurse (LPN) #140 stated Resident #44 had his left hip replaced before he arrived at the facility and he had previously fallen on it and it causes him a lot of pain. She also stated they have completed X-Rays on the hip and there is nothing that is compromised. They try repositioning which is normally effective. LPN #140 revealed she reassessed Resident #44's pain in the early afternoon, after his first dose of the Oxycodone, and he was still experiencing an eight out of 10 pain to his left hip. She stated she notified the physician and they ordered lab work. She stated she offered him Tylenol but he refused it and there were no further pain relieving interventions completed. The LPN #140 stated Resident #44 was able to have another as needed Oxycodone at 2:00 P.M., but she was busy and never administered it. She stated she would go administer it right now if he was still in pain. Observation and interview on 12/21/22 at 4:15 P.M. with Resident #44 revealed he was in eight out of 10 pain for his left hip, he stated the pain is constant and a thumping pain and it hurts so bad at times that he gets tearful. He stated after pain pills the pain does normally mellow out but he felt an ice pack would help. The resident was lying in bed and would readjust himself often, during readjustments his face would grimace. Review of the facility policy and procedure titled Pain Management Program Policy, dated 11/12/14 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 47 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few revealed its the facilities policy to manage and recognize residents pain in order to assist residents to attain and/or maintain their highest practicable level of well-being and to prevent or manage pain, to the extent possible. 2. Medical record review revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, shortness of breath, chronic kidney disease, heart failure, and history of falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had mild impaired cognition and required extensive assistance from two staff members for bed mobility, transfers, and toilet use. Review of the active care plans for Resident #28 revealed no care plans addressed actual or potential pain. Review of the active physician order dated 11/21/22 revealed an order to monitor pain level every shift for pain management. Further review of the active physician orders revealed no medication ordered to treat pain. Review of the Treatment Administration Record (TAR) for 11/21/22 through 12/27/22 revealed the resident pain level was documented as zero every shift, indicating the resident had no pain. Review of the nurses progress notes dated from 12/20/22 through 12/27/22 revealed no documentation of Resident #28 experiencing pain or notification to the physician or hospice staff of pain being experienced by the resident. Observation on 12/21/22 at 10:55 A.M. revealed State Tested Nursing Assistant (STNA) #226 was providing incontinence care to Resident #28. The residents groin, inner thighs, peri-area, and buttocks were observed severely excoriated and deep red in color. While cleansing the residents peri-area and groin, the resident began yelling That hurts while grimacing and tensing up. Resident #28 asked STNA #226 why it was hurting and STNA #226 told Resident #28 it always hurt like this when we cleaned you because you are raw. STNA #226 then proceeded to clean the remainder of the residents groin, inner thighs, peri-area, and buttocks while the resident continued to grimace and voice complaints of pain which the resident verbally rated as a nine out of 10 pain rating. Interview with the LPN #222 on 12/21/22 at 2:10 P.M., revealed there had been no reports from staff of Resident #28 experiencing pain during the shift. LPN #222 stated the resident usually responded well to the administration of Tylenol for pain, then verified the resident had no active orders for Tylenol to be administered for pain. Telephone interview with the Hospice Registered Nurse (HRN) #700 on 12/21/22 at 2:45 P.M., revealed she had believed Resident #28 had Tylenol ordered every six hours as needed for pain and would follow up with the facility. 3. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, unspecified mood disorder, pain in right wrist, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed Resident #25 had severely impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 48 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 cognition. Level of Harm - Actual harm Review of the physician's orders for Resident #25 revealed an order dated 12/13/22 for Lidocaine Patch five percent applied to the lower back topically one time a day for pain and removed per the schedule. Additional orders dated 12/07/22 for Tramadol HCL 50 milligrams (mg) one tablet by mouth every eight hours for pain and orders dated 11/29/22 for Tramadol HCL 50 mg one tablet by mouth every six hours as needed for pain. Residents Affected - Few Review of Resident #25's progress note dated 12/08/22 revealed Lidocaine Patch five percent was on order. Review of Resident #25's progress notes dated 12/13/22, 12/18/22, 12/19/22 revealed Lidocaine Patch five percent was indicated as having an order administration note, however nothing was indicated. Review of Resident #25's progress note dated 12/12/22 at 3:13 P.M. revealed Tramadol HCL tablet 50 mg was not available, and a script was called to hospice. Review of Resident #25's progress note dated 12/13/22 at 6:05 A.M. revealed the Tramadol HCL tablet 50 mg was not available and they were waiting on the pharmacy medication drop, the 10:18 A.M. progress note revealed no order administration notes for Tramadol, and the 4:10 P.M. progress note revealed Tramadol was not available, a new script was sent and awaiting authorization. Review of Resident #25's progress notes dated 12/14/22 at 4:53 A.M. and 12/15/22 at 8:10 A.M. and 3:24 P.M. revealed Tramadol HCL Tablet 50 mg was not available. Review of Resident #25's progress note dated 12/16/22 at 6:47 A.M. revealed hospice was contacted about getting a new script for Tramadol 50 mg. Review of Resident #25's progress note dated 12/16/22 at 10:51 A.M. and 3:20 P.M. and 12/17/22 at 12:46 A.M. and 9:05 A.M. revealed Tramadol HCL Tablet 50 mg was on order. Review of Resident #25's Medication Administration Record (MAR) for December 2022 revealed the Lidocaine Patch five percent was not administered on 12/08/22, 12/13/22, 12/18/22 and 12/19/22 and the MAR indicated there were order administration notes. Review of Resident #25's Medication Administration Record (MAR) for December 2022 revealed for Tramadol HCL Tablet 50 mg every eight hours on 12/12/22, 12/15/22, and 12/16/22 at 12:00 A.M. and on 12/14/22 at 8:00 A.M. and 4:00 P.M. there was no administration documentation. Additionally, on 12/12/22 at 4:00 P.M., on 12/13/22 at all administration times, on 12/14/22 at 12:00 A.M., on 12/15/22 at 8:00 A.M. and 4:00 P.M., and on 12/17/22 at 12:00 A.M. and 8:00 A.M. Tramadol was not administered, and the MAR indicated there were order administration notes. On 12/16/22 at 8:00 A.M. and 4:00 P.M. the MAR indicated the medication was on hold and to see nurse's notes. Review of the controlled substance record for Tramadol HCL tablet 50 mg revealed Resident #25 was out of Tramadol beginning on her 4:00 P.M. dose on 12/12/22 until her 4:00 P.M. dose on 12/17/22. Additional review revealed Resident #25 was not given her 12/20/22 4:00 P.M. dose of Tramadol despite it being indicated on the MAR. Interview on 12/21/22 at 2:21 P.M., and 4:29 P.M., and on 12/27/22 at 10:50 A.M., with the Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 49 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of Nursing (DON) revealed the Lidocaine patches were on back order, she did not know why the order was not placed on hold. The DON verified Resident #25 was out of Tramadol from her 12/12/22 to 12/17/22, she believed there was a problem with how hospice wrote the script, she additionally said Tramadol was not administered as ordered on 12/19/22. The DON verified there was no documentation to indicate the physician was aware Resident #25 was out of either pain medications. Event ID: Facility ID: 366435 If continuation sheet Page 50 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure documentation of appropriate dialysis port monitoring and communication between the facility and dialysis. This affected one resident (#22) out of one resident reviewed for dialysis. The facility identified two residents (#22 and #61) who received dialysis services. The census was 84. Residents Affected - Few Findings Include: Review of the medical record for Resident #22 revealed an admission date of 10/28/22 and the diagnoses of end stage renal disease (ESRD), non compliance with renal dialysis, diabetes type two, morbid obesity, need for assistance with personal care, high blood pressure, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview of Mental Status (BIMS) of 15 indicating impaired cognition and the resident required extensive assistance of one staff for bed mobility, personal hygiene and toilet use and extensive assistance of two staff for transfers. It stated the resident had weight gain and was on a therapeutic diet. Review of the November 2022 and December 2022 physician orders revealed orders to monitor the dialysis site, port on right side of chest every shift, initiated 12/18/22. There was no documented evidence of port site monitoring prior to 12/18/22. Review of Resident #22's care plan dated 11/08/22 revealed the resident had a need for dialysis related to renal failure with instructions to have dialysis Mondays, Wednesdays, and Fridays. Interventions included check and change dressing daily at access site if needed and document. Review of the dialysis communication forms revealed the facility was to complete a pre-dialysis assessment, the dialysis center was to complete an assessment, then the facility would complete a post dialysis assessment. The facility provided one dialysis communication form for Resident #22 during his stay. The forms revealed on 11/07/22 the facility completed a pre-dialysis assessment, dialysis completed an assessment, but there was no post-dialysis assessment completed by the facility. Review of the hemo-dialysis treatment spreadsheet from the dialysis center revealed Resident #22 received dialysis 13 times from 10/28/22 (admission) to 12/16/22. Interview on 12/21/22 2:26 P.M., with the Director of Nursing (DON) revealed every shift should be observing the port site for redness and signs/symptoms of infection. She verified the absence of documentation for the monitoring of the port site and no additional communication with dialysis besides one form. Review of the policy and procedure titled Dialysis Resident: General Care Guidelines, dated 08/11/10 revealed the facility will communicate updates and relevant concerns to the dialysis center, the dialysis center will communicate updates and relevant concerns to the facility, the facility and the dialysis center will exchange pertinent information regarding the resident that may impact or affect dialysis care, and the facility will monitor for signs and symptoms of infection at the dialysis site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 51 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the medical record for Resident #13 revealed an admission date of 11/16/22 and the diagnoses of Parkinson's disease, depression, cramps and spasms, high blood pressure, muscle weakness, muscle contracture's, and reduced mobility. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had a Brief Interview of Mental Status (BIMS) of 13 indicating intact cognition and she required extensive assistance of two staff for transfers and bed mobility and she required total dependence of one staff for locomotion via wheelchair. It further stated it is very important to her to attend her favorite activities, though it does not state what her activity preferences were. Review of Resident #13's care plan dated 11/21/22 revealed the resident was to reside at the facility in long term placement with interventions to encourage participation in activities of choice. The care plan dated 12/06/22 revealed the resident had an activities of daily living (ADL) self care performance deficit and was at risk for a decline in ADL self-performance and associated complications related to Parkinson Disease, bilateral lower extremity contracture's and contracture of upper extremity for which she wears braces. Interventions included encourage the resident to participate to the fullest extent possible with each interaction and the resident was dependent on staff for daily care with bed mobility, transferring and mobility. Review of Resident #13's activity log for December 2022 revealed from 12/01/22 through 12/18/22, Resident #13 only attended one Bingo activity out of 15 opportunities. Review of the December 2022 Activity Calendar provided (but was dated December 2021) revealed on 12/19/22 Bingo was at 10:00 A.M., and on 12/20/22 and 12/21/22 Bingo was at 11:00 A.M. Observation and interview on 12/19/22 at 11:04 A.M. with Resident #13 revealed she was in bed doing word search. She stated that was the activity for the day. She stated no one invited her to bingo this morning and she really likes bingo. Interview on 12/20/22 at 8:03 A.M. with Activities Director #154 revealed Resident #13 likes Bingo, among other activities. She stated if the resident is up and wants to go to activities, then she goes. Interview on 12/21/22 at 9:19 AM with Activities Assistant #182 revealed he was conducting Bingo on this date at 11:00 A.M. he stated he notifies the residents every morning of the activities and they use calendars, then the residents tell them if they want to go or not. He stated Resident #13 will go to activities if they get her out of bed, and if they dont get her up, she wont go. He stated activities staff will ask the aides to get her up for the activities, but they dont always listen. He further revealed Resident #13 likes activities and would come often if the aides would get her up. Observation on 12/21/22 at 11:03 A.M. revealed the Bingo activity was going on in the activities center, Resident #13 was not present. Observation and interview on 12/21/22 at 11:05 A.M. with Resident #13 revealed she wanted to go to Bingo and they didn't invite her to Bingo today. The resident was in her room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 52 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 12/21/22 at 11:39 A.M. with State Tested Nurse Assistant (STNA) #219 revealed the aide staff ask residents when they ' re getting them ready if they want to go to activities. She stated she didn't ask Resident #13 if she wanted to go to Bingo on this day. She also stated she had not seen activities staff today so they never told her that Resident #13 wanted to go to Bingo. STNA #219 stated the nurses on all units dont help the aides, they put one aide with one nurse, but they dont all help the aides. She stated she is happy when the State Agency is here because the aides get all the help they need. She stated for example call lights go off longer than they should and they have to do care for some with less than the assistance required, and when state isn ' t here, there is not enough help to get things done on time. Observation and interview on 12/21/22 at 2:07 P.M. with STNA #219 and Activities Assistant #182 revealed Resident #13 up in her wheelchair. The Activity Assistant stated it would increase her quality of life if she could go to activities regularly. The Activity Assistant walked up to Resident #13 and asked if she would like to go to the Moving and Music activity and the resident stated yes with a smile on her face. Observation and interview on 12/21/22 at 4:07 P.M. with Resident #13 revealed she was back in her room from activities and smiling. She stated she had a great time at activities. This deficiency represents non-compliance discovered in Complaint Numbers OH00138037, OH00137957, OH00135966, and OH00135623. Based on medical record review, observation, interview, and review of the Centers for Medicare and Medicaid (CMS) Census and Condition form 672, the facility failed to ensure sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all 84 residents residing in the facility. Findings include: 1. On 12/18/22 at 8:00 A.M. upon entrance of the facility there were four nurses and seven State Tested Nursing Assistants (STNA's) on duty to provide care for the 84 residents residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility had no residents who were independent for activity of daily living care. The facility identified 73 residents who required the assistance of one or two staff for bathing and 11 who were dependent on staff for bathing. The facility identified 80 residents who required the assistance of one or two staff for dressing and four staff who were dependent on staff for dressing. The facility identified 73 residents who required the assistance of one or two staff for transferring and five residents who were dependent on staff for transferring. The facility identified 73 residents who required the assistance of one or two staff for toilet use and six residents who were dependent on staff for toilet use. The facility identified 38 residents who required the assistance of one or two staff for eating and nine who were dependent on staff for eating. The 672 form also identified 74 of 84 residents who were occasionally or frequently incontinent of bladder and 72 of 84 residents who were occasionally or frequently incontinent of bowel. 2. The following resident and family concerns were lodged during the annual and complaint investigation related to facility staffing: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 53 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many a. On 12/18/22 at 10:38 A.M. interview with Resident #38's family revealed she felt the facility was short staffed. Reported she has had to change the resident's linen because there was one staff person on the unit and they said they could not help because they had to help the other residents. b. On 12/18/22 at 12:04 P.M. interview with Resident #25's family reported the memory care unit was insufficiently staffed. He reported there was one aide assigned downstairs and the nurse assigned also worked another unit. He reported he had concerns related to incontinence care because of this and he did not feel the residents were being supervised. c. On 12/18/22 at 1:20 P.M. interview with Resident #63 revealed the call light times were extended related to short staffing. d. On 12/18/22 at 4:53 P.M. interview with Resident #76's family revealed there was often only one staff member in the memory care unit. They reported one staff member was not enough to meet everyone's care needs. e. On 12/18/22 at 1:22 P.M. interview with Resident #31 revealed staff took thirty minutes or longer to answer call lights. f. On 12/18/22 at 10:05 A.M. interview with Resident #28 revealed there was an extended wait for staff to come or provide care and they did not always get the care they needed. g. On 12/27/22 at 12:54 P.M. interview with Resident #21 revealed there were insufficient staff to provide timely care. 3. The following staff concerns were lodged during the complaint investigation related to facility staffing: a. On 12/18/22 at 10:54 A.M. interview with Registered Nurse (RN) #168 revealed there was not enough staff in the facility. They revealed there was one aide on the unit but two was needed to meet needs in the morning. b. On 12/18/22 at 11:30 A.M. interview with State Tested Nursing Assistant (STNA) #187 and Licensed Practical Nurse (LPN) #192 revealed in the memory care unit there was usually one aide assigned and one nurse who also worked the assisted living. STNA #187 reported four to five residents needed two-person assistance. She stated when one of those residents needed care they either needed to wait for the nurse to come back or do what she had to do. LPN #192 reported when she worked this unit she attempted to spend as much time as possible in the memory care unit so she could watch residents while the aide was in resident rooms. c. On 12/27/22 at 11:04 A.M. with LPN #222 revealed there was insufficient staff to pass medications timely and provide care to residents. LPN #222 reported there were times aides have to provide care with just one person instead of two as required. d. On 12/28/22 at 12:09 P.M. interview with Registered Nurse #165 revealed the facility currently had inconsistent staffing. e. On 12/28/22 at 2:32 P.M. interview with the Director of Nursing (DON) revealed the facility had the same problems with staffing that everyone currently had and they relied on agency staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 54 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 Level of Harm - Minimal harm or potential for actual harm 4. During the onsite annual and complaint investigation concerns were identified related to residents not receiving activity of daily living assistance. This concern was correlated to a lack of staff. a. Observation on 12/18/22 and 12/19/22 revealed Resident #76 had greasy hair that had been combed back. Residents Affected - Many Interview on 12/19/22 at 12:50 A.M. with State Tested Nursing Aide (STNA) #187 revealed Resident #76 was to be showered on Tuesdays and Fridays and required staff assistance with this. She reported showers were not always able to be completed due to insufficient staffing. Interview on 12/20/22 at 8:15 A.M. with STNA #187 revealed she had been able to get Resident #76 a shower that morning because she was not the only aide downstairs. Review of the medical record for Resident #76 revealed an admission date of 08/20/22 with diagnoses including neurocognitive disorder with lewy bodies, Parkinson's disease, dementia, unspecified severe protein-calorie malnutrition, alcohol abuse, major depression. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a severe cognitive impairment. He required physical help of one person in part of bathing. Review of the plan of care dated 09/09/22 revealed Resident #76 had an actual or limited physical mobility related to history of falls, dementia, and severe protein calorie malnutrition. Interventions included hands on assistance with activities of daily living, monitor the resident's ability to perform in mobility activities, and observing for and reporting to the physician signs of immobility. Review of Resident #76's documented showers from 11/19/22 to 12/18/22 revealed the resident received a bed bath on 11/20/22, 11/25/22, 11/26/22, 12/8/22, 12/9/22, and 12/15/22. The resident was missing showers on 12/13/22, 12/6/22, 12/2/22, 11/28/22, and 11/20/22. Review of the shower schedule revealed Resident #76 should have received showers on Tuesdays and Fridays. b. Interview on 12/19/22 at 11:26 A.M. with Resident #25's family revealed it was thought there was some confusion on whether the facility or hospice was supposed to be doing her bathing. Resident #25's family revealed an aide had reported hospice did her baths now and he was worried she might not be getting them. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, unspecified mood disorder, pain in right wrist, and unspecified osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Resident #25 required the physical help of one person in bathing. Review of the plan of care dated 05/10/21 revealed Resident #25 had an activity of daily living self-care performance deficit related to impaired mobility, weakness and deconditioning. Interventions included conversing with the resident while providing care, monitoring and reporting any changes to the nurse, promoting dignity by ensuring privacy, and hands on assistance for bathing, bed mobility, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 55 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 dressing, eating, transfers, and toilet use. Level of Harm - Minimal harm or potential for actual harm Review of the hospice aide's documentation revealed on 12/08/22 Resident #25 did not receive a bath because the task was already completed, on 12/14/22 Resident #25 received a bed bath, and on 12/19/22 a bed bath was not required. Residents Affected - Many Review of the Resident #25's facility documented showers from 11/19/22 to 12/18/22 revealed she received a shower on 11/26/22 and a bed bath on 12/14/22. Interview on 12/20/22 at 8:15 A.M. with STNA #187 revealed Resident #25's bathing schedule was changed after discussion with hospice to Monday and Wednesday. She reported bathing for Resident #25 was joint between the facility and hospice, however, bathing was not always able to be completed due to insufficient staffing. c. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] and had diagnoses including paroxysmal atrial fibrillation, chronic diastolic heart failure, unspecified severe protein-calorie malnutrition, shortness of breath, chronic kidney disease, hypothyroidism, hypertension, muscle weakness, cardiac murmur, heart failure, and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting and limited assistance from one staff member for eating. This resident was assessed to always be incontinent of bowel and bladder. Review of the care plan dated 03/07/22 revealed Resident #28 had incontinence episodes and/or was at risk for bladder incontinence. Occasionally incontinent. Interventions included to notify nursing if incontinent during activities, check and record bowel movement status every shift, and document and report to nurse any change in voiding pattern. Review of the care plan, dated 03/07/22 and revised on 11/23/22, revealed Resident #28 had a self care deficit. Upon return from hospital the resident would need assistance of care times two team members and to check and change every two hours. Interventions included to check and change every two hours with two team members, resident needs setup with meals, cut up then cueing, two staff members in room for all care, and requires hands on assist with bed mobility. Review of the active physicians order dated 11/21/22 revealed an order to toilet Resident #28 every two hours. Observation and interview on 12/18/22 at 10:30 A.M. revealed Resident #28 was lying in bed and had urinated and was in need of being changed. State Tested Nursing Assistant (STNA) #228 was present in the room and verified the resident had urinated and needed changed and she was unable to toilet herself. STNA #228 stated Resident #28 had not had incontinence care provided since the beginning of the shift at 7:00 A.M., which was three and half hours prior. STNA #228 stated there was not enough staff present to provide incontinence care every two hours. Observation on 12/21/22 at 10:55 A.M. revealed STNA #226 was providing incontinence care to Resident #28. The residents groin, inner thighs, peri-area, and buttocks were observed severely exoriated and deep red in color. While cleansing the residents peri-area and groin, the resident began yelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 56 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that hurts while grimacing and tensing up. Resident #28 asked why it was hurting and STNA said it always hurts like this when we cleaned you because you are raw. Interview with STNA #219 on 12/21/22 at 11:58 A.M. revealed there were not sufficient staffing levels present in the facility to provide incontinence care every two hours. STNA #219 stated many residents on her assignment had only had incontinence care provided once during the shift which had started at 7:00 A.M., five hours earlier. Interview with Licensed Practical Nurse (LPN) #222 on 12/21/22 at 2:10 P.M. verified staff were unable to provide incontinence care every two hours due to not having sufficient staffing levels. d. Review of the active physicians order for Resident #28 dated 07/28/22 revealed an order to float heels when in the bed and document refusals. Review of the active physicians order dated 11/21/22 revealed an order to turn and reposition resident every two hours and as needed. Review of the Resident #28's Treatment Administration Record (TAR) for 10/2022, 11/2022, and 12/2022 revealed no documentation of refused treatments or physicians orders. Observation and interview on 12/18/22 at 10:30 A.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress. State Tested Nursing Assistant (STNA) #228 verified the residents legs and heels were not elevated. Observation on 12/19/22 at 11:15 A.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated. Observation on 12/19/22 at 1:30 P.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated. Observation and interview on 12/19/22 at 4:15 P.M. revealed Resident #28 was lying in bed on her back. The residents legs and heels were lying flat against the mattress and were not elevated. STNA #126 verified the residents legs and heels were lying directly against the bed mattress and were not elevated. STNA #126 stated there was not always enough staff to turn and reposition residents every two hours and denied knowledge of the last time Resident #28 had been turned or repositioned in bed. 5. During the onsite annual and complaint investigation concerns additional concerns with staffing were identified related to timely call lights. a. Observation on 12/18/22 at 1:58 P.M. revealed the emergency call light for room [ROOM NUMBER] was observed to be activated. Observation of the facility electronic call light board, located at the nurses station of the B unit, revealed the emergency call light had been active for 19 minutes. Interview with State Tested Nursing Assistant (STNA) #228 at the time of the observation verified the emergency call light had been active for 19 minutes without being answered. STNA #228 further stated there was not always enough staff to answer call lights timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 57 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on staff interview and review of the personnel records, the facility failed to ensure State Tested Nurse Assistant's (STNA) received performance evaluations. This had the potential to affect all 84 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel records for STNA #200 (date of hire 09/21/21), STNA #177 (date of hire 06/25/21), STNA #124 (date of hire 01/28/21), and STNA #210 (date of hire 10/31/18) revealed no documented evidence of annual performance evaluations. Review of personnel records for STNA #132 (date of hire 03/03/22) and STNA #227 (date of hire 09/29/22) revealed no documented evidence of 90-day performance evaluations for either STNA. Interview on 12/20/22 at 8:47 A.M., with Human Resources #117 verified the absence of performance evaluations for the six staff members. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 58 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Medscape prescribing information, staff interviews, and record reviews, the facility failed to ensure the appropriate monitoring of abnormal behaviors, failed to ensure medications were used for the appropriate indication, and failed to ensure medications were held as ordered by the physician when vital signs were outside the ordered parameters. This affected four residents (#5, #28, #49, and #73) of the 26 residents whose records were reviewed during the annual survey. The facility census was 84. Residents Affected - Some Findings include: 1. Record review for Resident #28 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation, chronic diastolic heart failure, hypertension, cardiac murmur, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/16/22, revealed Resident #28 had mildly impaired cognition. Review of the active physician's order, dated 12/02/22, revealed Resident #28 was to be administered one half of a 200 milligram (mg) tablet of Amiodarone once daily for dysrhythmia and to hold if heart rate was less than 70 beats per minute (BMP). Review of the physician's order, dated 12/02/22 and discontinued on 12/06/22, revealed Resident #28 was to be administered 30 mg of Diltiazem every 12 hours and to hold if heart rate was less than 90 BMP. Review of the Medication Administration Record (MAR) for 12/2022 revealed documentation Amiodarone was administered on 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/06/22, 12/07/22, and 12/10/22 with no heart rate documented, was administered on 12/16/22 with a documented heart rate of 62, and was administered on 12/20/22 with a documented heart rate of 67. Diltiazem was documented to be administered on 12/03/22 at 9:00 A.M. with a documented heart rate of 88, was administered on 12/03/22 at 9:00 P.M. with a documented heart rate of 74, and was administered on 12/04/22 at 9:00 P.M. with a documented heart rate of 76. Interview with the Director of Nursing on 12/27/22 at 3:45 P.M. verified multiple doses Amiodarone and Diltiazem were documented as being administered to Resident #28 despite the heart rate not being documented or being below the parameters ordered by the physician. 2. Record review for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with agitation and generalized anxiety disorder. Review of the quarterly MDS assessment, dated 11/25/22, revealed Resident #49 had severely impaired cognition. Review of the physician's order, dated 12/20/22, revealed Resident #49 was to be administered Depakote (an anticonvulsant medication) twice a day for dementia. Interview with the Director of Nursing on 12/27/22 at 3:45 P.M. verified Resident #49 was receiving Depakote for a documented diagnoses of dementia. Review of the Medscape prescribing information at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 59 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some https://reference.medscape.com/drug/depakote-divalproex-sodium-999832#0 for Depakote revealed Depakote was utilized for the treatment of manic episodes associated with bipolar disorder and epilepsy. 3. Review of the medical record for Resident #73 revealed an admission date of 06/29/22. Diagnoses included dementia and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #73 had severely impaired cognition. No behaviors were indicated. Review of the progress note dated 07/05/22 revealed the Assistant Director of Nursing (ADON) was made aware that Resident #73 had a history of sexual behaviors. The Certified Nurse Practitioner (CNP) was notified, and Tagamet (can treat for hypersexuality) 800 milligrams (mg) was ordered twice a day. Review of the plan of care dated 07/11/22 revealed Resident #73 had the potential to exhibit behavior signs related to sexual behaviors. Interventions included developing behavioral contract for acceptable behaviors, documenting all attention seeking behaviors, review behavioral logs to determine possible causes, and staff to assist back to room when having sexual behaviors. Review of the CNP's note dated 07/14/22 revealed Tagamet was not effective, and Resident #73 was started on Depakote for behaviors. Review of Resident #73's physician order dated 07/14/22 revealed an order for Depakote Sprinkles capsule delayed release 125 milligrams (mg) one capsule by mouth two times a day for sexual behaviors. The physician order dated 10/18/22 revealed an order for Tagamet tablet 800 mg by mouth one time a day for behaviors. Review of the medical record revealed no evidence of sexual behaviors or monitoring and tracking of sexual behaviors. Interview on 12/27/22 at 2:12 P.M. with the Director of Nursing (DON) confirmed there was no documentation monitoring sexual behaviors. She reported she had spoken to the CNP who reported the diagnosis for Depakote was entered wrong, however, she confirmed the 07/14/22 note indicate it was started for sexual behaviors. She reported she had requested a gradual dose reduction (GDR) as one had not been done before. 4. Review of the medical record for Resident #5 revealed an admission date of 02/11/18 with diagnoses including dementia and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had severely impaired cognition. Review of the plan of care dated 05/12/18 revealed Resident #5 had a mood problem related to admission, major depression, anxiety, and restlessness. Interventions included administering medications as ordered, behavioral health consults as needed, documenting and reporting significant mood patterns, observing for signs of mania, and reviewing and assessing mood changes. Review of the physician order dated 07/30/22 revealed an order for Depakote Sprinkles capsule delayed release 125 milligram (mg) give 125 mg by mouth one time a day for bipolar disorder and give 250 mg by mouth one time a day for bipolar disorder. Review of the medical record revealed no evidence Resident #5 had bipolar disorder (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 60 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 12/20/22 at 9:21 A.M. and 11:13 A.M. with the Director of Nursing (DON) confirmed Resident #5 did not have bipolar disorder and she switched the diagnosis to dementia. Subsequent review of the physician order dated 12/20/22 revealed an order for Depakote Sprinkles Capsule Delayed Release Sprinkle 125 mg give 125 mg by mouth one time a day for dementia with behavioral disturbance and give 250 mg by mouth one time a day for dementia with behavioral disturbance. Subsequent interview on 12/28/22 at 3:58 P.M. with the DON revealed they had identified an issue with medications and diagnoses for dementia. The DON was unable to provide evidence dementia was an indicated use for Depakote. Review of the Medscape prescribing information at https://reference.medscape.com/drug/depakote-divalproex-sodium-999832#0 for Depakote revealed Depakote was utilized for the treatment of manic episodes associated with bipolar disorder and epilepsy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 61 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 staff interview, review of the Medscape prescribing information, and record review, the facility failed to ensure there was an appropriate diagnosis for the use of the antipsychotic medication Seroquel for Resident #76. This affected one (Resident #76) of five residents reviewed for unnecessary medication. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 08/20/22. Diagnoses included neurocognitive disorder with lewy bodies and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #76 had a severe cognitive impairment. He had verbal behavioral symptoms for one to three days during the lookback period. Review of the plan of care dated 11/17/22 revealed Resident #76 had behaviors possibly related to Parkinson's disease, history of alcohol abuse, neurocognitive disorder with lewy bodies along with dementia, and other comorbidities. Interventions included administering medications as ordered. Review of Resident #76's physician order dated 11/15/22 to 12/20/22 revealed an order for Seroquel tablet 25 milligrams (mg) to be given by mouth every eight hours for lewy body dementia. The physician order dated 12/20/22 revealed an order for Seroquel tablet 25 mg to be given by mouth every eight hours for schizoaffective disorder. Interview on 12/20/22 at 11:13 A.M. with the Director of Nursing (DON) revealed she had requested the diagnosis from dementia to schizoaffective disorder the day before. The DON stated she had spoken to the certified nurse practitioner (CNP) about getting a diagnosis of schizoaffective disorder. The DON was unable to provide documentation supporting a behavior pattern indicating the change in diagnosis. Review of the Medscape prescribing information for Seroquel at https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984#0 revealed indications for use included schizophrenia, acute treatment of manic episodes associated with bipolar disorder, acute treatment of depressive episodes associated with bipolar disorder, and maintenance treatment of bipolar disorder in conjunction with lithium or divalproex. The information indicates a warning stating the medication is not approved for elderly patients with dementia related psychosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 62 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the facility policy, observation, and staff interview, the facility failed to ensure the medication error rate was less than five percent. There were ten medication errors out of 35 opportunities observed, resulting in 28.57% (percent) medication error rate. This affected one (#31) of three residents observed for medication administration. The facility census was 84. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 08/27/21. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus type II, dysphagia, and gastrostomy (an opening in the stomach to receive to receive artificial nutrition) malfunction. Review of the active physician orders for Resident #31 revealed an order for Vitamin D (vitamin) one tablet, Cymbalta (antidepressant) 50 milligrams (mg) one tablet, Prednisone (steroid) one mg one tablet, Hydroxychloroquin (antimalaria) 200 mg one tablet, Xanax (antianxiety) 0.25 mg one tablet, Oxycodone (narcotic pain medication) liquid 0.5 mg, Senna (treats constipation) 8.6 mg one tablet, Esomeprazole (reduces stomach acid) 40 mg packet, Keppra (treats seizures) 750 mg two tablets, and Miralax (laxative) 17 gram. All medications to be provided via g-tube. Observation on 12/20/22 at 8:40 A.M. of the medication administration pass with Licensed Practical Nurse (LPN) #192 revealed Resident #31 received medications including: Vitamin D, Cymbalta, Prednisone, Hydroxychloroquin, Xanax, and Oxycodone. Resident #31 was not observed to receive Esomeprazole, Keppra, or Miralax. LPN #192 verified at the time of the administration, this was all of Resident #31's medications and she had not given any medicine earlier. Of the remaining medications provided, all medications were observed to be crushed in a single medication cup with a water flush before and after administration. All medications were cocktailed together and not administered separately. LPN #190 verified all medications provided were mixed together. Interview with LPN #192 on 12/20/22 at 9:20 A.M., verified all seven medications (Vitamin D, Cymbalta, Prednisone, Hydroxychloroquin, Xanax, and Oxycodone) were cocktailed and administered per PEG tube with exception of Esomeprazole 40 mg packet due to not available, Miralax due to not available, and Levitracetam 750 mg two tablets. LPN #192 stated Levitracetam was not administered due to the package label stating do not crush or chew before swallowing, and may have a bitter taste if chewed. LPN #192 stated she reached to the certified nurse practitioner (CNP) and waiting on reply regarding the administration of Levitracetam. Review of the facility policy titled Medication Administration Guidelines-Enteral Tube Medication, dated 03/01/18, revealed each medication provided via g-tube must be crushed in a double souffle cup method with each tablet dissolved in 10 to 15 ml of water for administration. Administer each medication separately, and additionally flush with five ml of water after each dose provided. This deficiency represents non-compliance investigated under Complaint Number OH00135966. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 63 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, and staff interviews, the facility failed to ensure an adequate system was in place for the timely review and reporting of laboratory and diagnostic results to the physician. This affected two (Resident #16 and #40) of six residents reviewed for laboratory services. The facility census was 84. Findings include: 1. Review of the medical record for Resident #16 revealed an admission dated of 04/09/21 with diagnoses including vascular dementia and cerebral infarction with hemiplegia and hemiparesis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had severely impaired cognition. Review of Resident #16's physician's order dated 11/13/22 revealed an order for blood work and a urinary analysis one time only until 11/14/22. An additional order was written for 11/16/22 through 11/19/22 for blood work and urinary analysis to be drawn and collected on one of these selected dates with results to be sent to MedOne (physician's services). Another order dated 11/23/22 for a urinary analysis to be collected on that day with the results sent to MedOne. Review of the laboratory results collected and reported on 11/16/22 to 11/21/22 revealed the urine specimen was not collected. Review of the progress note dated 11/22/22 revealed a new order for a urinary analysis, the urine was collected on that date and an order was placed for the urine to be picked up on 11/23/22. Review of the laboratory results collected on 11/23/22 and reported on 11/25/22 revealed the urine culture revealed organisms growing. The physician or CNP did not respond the urine culture results until five days later on 11/29/22. Review of the progress note dated 11/29/22 revealed the urinary analysis results were sent to the CNP, there were new orders for Macrobid (antibiotic) 100 milligrams (mg) twice a day for seven days. Interview on 12/21/22 at 2:21 P.M. with the Director of Nursing (DON) confirmed Resident #16's urinary analysis was not reported in a timely manner. Further interview on 12/28/22 at 11:02 A.M. revealed the labs were managed by the Assistant Director of Nursing (ADON). The ADON would keep track of the orders and upload the results in the electronic medical record. The DON reported the labs did not automatically go into the electronic medical record and the nursing staff would need to look up to see if results were in. She reported the gap in reviewing the results could have been because it was agency staff. 2. Record review for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, protein-calorie malnutrition, anemia, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/29/22, revealed Resident #40 had moderately impaired cognition. Review of the physician order, dated 08/26/22, revealed an order for a Complete Blood Count (CBC) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 64 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0773 Level of Harm - Minimal harm or potential for actual harm and Basic Metabolic Panel (BMP) to be completed. The medical record had no evidence of the results of the CBC and BMP. Further review of the medical record for Resident #40 revealed no documentation related to the results of the CBC and BMP or the physician notification of the results. Residents Affected - Few Interview with the Director of Nursing (DON) on 12/27/22 at 2:37 P.M. verified there was no documentation present in Resident #40's medical record regarding the results of the CBC and BMP or the physician notification of the results. The DON stated she found the laboratory values were drawn on 08/27/22 with review of the laboratory contract services during the annual survey. Subsequent interview with the DON on 12/28/22 at 11:10 A.M. revealed there was no exact process at the facility for monitoring laboratory and diagnostic tests were being completed and reviewed by the physician. Interview with Registered Nurse (RN) #165 on 12/28/22 at 12:09 P.M. revealed laboratory and diagnostic test results were uploaded directly from the laboratory to the resident's Electronic Health Record (EHR) with no paper copies being received by the facility. RN #165 stated results of testing were either texted or called into the physician while others were reviewed by physicians who had access to the resident's EHR. RN #165 stated the review of the laboratory and diagnostic results by the physician should be documented in the resident's EHR. RN #165 stated more consistent staffing would help with the continuity of test results being reviewed and documented. Review of the policy titled Lab Policy and Procedure dated 10/10/13, revealed results should be reviewed from the vendor and abnormal labs should be reported to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 65 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the facility policy, observations, staff interviews, and record review, the facility failed to follow the planned menu on two different occasions. This affected all residents residing on all units, except for Resident #71 who was identified as consuming nothing by mouth. The facility census was 84. Findings include: 1. Observation of the lunch meal on 12/20/22 revealed the menu was not followed on Unit B, Unit C, and memory care. Observations included: a. On Unit B, a side salad was served in a small white Styrofoam bowl, the observed salad included lettuce and tomato and took up less than half of the bowl. Interview at that time with Dietary Aide #144 confirmed the salad. Dietary Aide #144 reported every resident on the unit received three ounces of salad. b. The test tray from Unit B revealed a side salad, the eight-ounce bowl was less than half full of lettuce and had five small slices of tomato. c. On the memory care unit, a side salad was served in a small white bowl, it included lettuce and parmesan cheese and took up half of the bowl. Interview at that time with Dietary Director #172 confirmed she was serving half a cup of salad with parmesan cheese. d. On Unit C, a side salad was served in a small white bowl, it included lettuce, tomato, and parmesan cheese and took up a little more than half of the bowl. [NAME] #148 reported the residents received four to six ounces of salad. Review of the therapeutic spreadsheet for the lunch meal on 12/20/22 revealed the residents were to receive one cup of tossed salad. Interview on 12/20/22 at 3:18 P.M. with Dietary Director #172 and Regional Dietitian #301 revealed the salads were served in eight-ounce bowls and all residents should have received one cup of salad, which included toppings. The salads were prepared by each cook in the main kitchen, she was unsure if there was a standardized recipe, and confirmed there were different toppings in salads. Dietary Director #172 confirmed the salad on the test tray was not a full cup of salad. Review of the policy titled Food and Nutrition Services, dated 11/20/17, revealed the facility was to provide menus that would be followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 66 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. Observation of the lunch meal on 12/20/22 revealed the menu was not followed on Unit A and the memory care unit, as well as for all the residents receiving a pureed diet. Observations included: a. Observation on 12/27/22 from 12:15 P.M. to 1:30 P.M. revealed Assistant Dietary Director #141 made pureed chicken, broccoli, potatoes, and cake. No puree bread was made or sent to the units. b. Observation of the lunch meal on Unit A revealed Assistant Dietary Director #141 was serving half a slice of bread for residents. Assistant Dietary Director #141 confirmed this observation. c. Observation of the lunch meal on the memory care unit revealed all residents' meals were served and bread was not provided. State Tested Nursing Aide (STNA) #87 confirmed the residents did not have bread. Review of the menu revealed the residents were to receive one slice of bread or roll for lunch. Interview on 12/27/22 from 2:00 P.M. to 2:10 P.M. with Dietary Director #172 confirmed the menu called for one slice of bread or roll. She confirmed if the Assistant Dietary Director #141 did not make puree bread than the residents on a puree diet did not receive bread. She reported she was the cook in the memory care unit and must have forgotten the bread. Review of the policy titled Food and Nutrition Services, dated 11/20/17, revealed the facility was to provide menus that would be followed. This deficiency represents non-compliance investigated under Complaint Numbers OH00137957 and OH00138037. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 67 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of the facility policy, observations, resident and staff interviews, and review of the mealtimes, the facility failed to serve meals according to the planned times and at regular mealtimes. This affected all but the 24 residents residing on Unit A. The facility census was 84. Findings include: Observation from 12/18/22 to 12/21/22 on Unit B, Unit C, and the memory care unit revealed meals were late on multiple occasions. These observations included: a. Observation of the lunch meal on 12/18/22 on Unit B revealed the first tray was served at 1:03 P.M. and the last tray was served at 2:00 P.M. Interview on 12/18/22 at 1:52 P.M. with Dietary Director #172 confirmed the meal came out late, she reported the cause was the kitchen being short staffed on that day. b. Observation of the lunch meal on 12/18/22 on the memory care unit revealed the first tray was served at 1:01 P.M. and the last tray was served at 1:37 P.M. Interview on 12/18/22 at 1:37 P.M. with State Tested Nursing Aide (STNA) #187 confirmed the late timing of the meal. STNA #187 reported the kitchen was short staffed, so meal times had been inconsistent recently. c. Observation of the lunch meal on 12/20/22 on Unit C revealed the first tray was served at 1:06 P.M. and the last tray was served to Resident #62 at 1:32 P.M. Interview on 12/20/22 at 12:52 P.M. with Resident #62 revealed the food was always late. Interview on 12/20/22 at 12:57 P.M. with Social Services #155 confirmed lunch was running late. d. Observation of the breakfast meal on 12/21/22 on the memory care unit revealed the first tray was served at 8:51 A.M. and the last tray was delivered at 9:17 A.M. Interview on 12/21/22 at 9:17 A.M. with STNA #115 confirmed the late time of the meal. e. Observation on 12/21/22 at 9:12 A.M. on Unit C revealed breakfast was still being served. Interview on 12/21/22 at 9:17 A.M. with Licensed Practical Nurse (LPN) #140 confirmed breakfast was running late. Observation on 12/21/22 at 9:29 A.M. revealed the last tray was delivered. Interview on 12/18/22 from 10:30 A.M. to 11:12 A.M. with Dietary Director #172 revealed the kitchen was short staffed. She reported she started four months ago and had four to five employees quit in that time. She reported breakfast had been late that day because of this. Further interview on 12/27/22 from 2:00 P.M. to 2:10 P.M. revealed each kitchenette should ideally have a cook and an aide, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 68 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0809 Level of Harm - Minimal harm or potential for actual harm currently due to staffing there was one staff member in each kitchen, and it was difficult to get meals out on time due to this. Review of the posted mealtimes revealed breakfast started at 8:15 A.M. and lunch started at 12:30 P.M., this was posted in all units. Residents Affected - Some Review of the policy titled Food and Nutrition Services dated 09/20/17, revealed residents would be provided with three meals a day at regular times comparable to normal mealtimes in the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 69 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #62 revealed an admission date of 10/14/22. Diagnoses included severe protein calorie malnutrition. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition and had required supervision from staff for eating. Resident #62 was on a therapeutic diet and had weight loss. Review of Resident #62's physician orders revealed no current orders for Ensure (high calorie nutritional supplement) supplements. Resident #62 was ordered Ensure pudding daily for nutritional support that was discontinued on 11/11/22 and changed to Ensure Plus twice daily for nutritional support from 11/11/22 through 11/18/22. Observation and interview on 12/20/22 at 12:52 P.M. with Resident #62 revealed she had just finished eating a vanilla Ensure pudding, she was holding the container (that looks like a pudding cup) and the spoon. She stated no one obtained it for her, it was in her refrigerator and she got it out and opened it herself. The expiration date on the Ensure was 12/01/22. Resident #62 granted the surveyor permission to look in her refrigerator and there was an unopened Ensure with an expiration date of 12/01/22 and some pudding in a bowl without a cover with a green hairy mold-like substance growing on it. Observation and interview on 12/20/22 at 12:57 P.M. with Social Services #155 confirmed the expired Ensure and the mold on pudding in the bowl in Resident #62's refrigerator. Social Services #155 stated the resident's family provided the Ensure. This deficiency represents non-compliance investigated under Complaint Numbers OH00138037 and OH00138377. Based on observations, record review, resident and staff interviews, and review of the facility's policy, the facility failed to keep the kitchen clean and failed to check expiration dates of food in Resident #62's refrigerator resulting in her eating expired food. This affected one (Resident #62) of three resident refrigerators observed and had the potential to affect all residents except Resident #71 who was identified as receiving no food from the kitchen. The facility census was 84. Findings include: Observation and interview on 12/18/22 revealed the facility had one main kitchen and four kitchenettes. Observation from 9:30 A.M. to 11:12 A.M. with Dietary Director #172 revealed the following concerns: a. In the main kitchen, multiple boxes were noted to be on the freezer floor. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 70 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 In the Unit A kitchenette, a bag of hot dogs was open and undated. Additionally, there were four containers of cereals that were open and undated. Observation of the hood above the oven revealed the vents had a buildup of grease. c. Residents Affected - Many In the Unit B kitchenette, the steam table had spills and rust colored stains down the front and on the shelf below the table. The top of the freezer, which was waist high and had food product stored on it, had multiple stains and spills. Observation of the hood above the oven revealed the vents had a buildup of grease. d. In the Unit C kitchenette, the reach-in refrigerator had multiple stains and food debris built up on the bottom, and the inside of the toaster had a large buildup of bread crumbs. In the refrigerator, there was an opened container of potato salad that was undated. Additionally, there were three open containers of cereal that were undated. Observation of the dishwasher revealed a large white stain on the floor underneath it leading under the sink and disposal. Additionally, the disposal was covered in unidentifiable stains. e. In the memory care unit, the steam table had spills and rust colored stains down the front and on the shelf underneath. Additionally, the microwave was not clean and had multiple stains Interview on 12/18/22 from 9:30 A.M. to 11:12 A.M. with Dietary Director #172 confirmed the observations. She did not think that dietary was responsible for cleaning the vents in the hoods. Observation on 12/27/22 from 12:15 P.M. to 1:30 P.M. revealed multiple boxes of food remained on the freezer floor. Interview on 12/27/22 from 2:00 P.M. to 2:10 P.M. with Dietary Director #172 confirmed the boxes of food remained on the freezer floor. Interview on 12/28/22 at 9:45 A.M. with Maintenance Supervisor #106 revealed he trained the kitchen staff, because they were responsible for cleaning the vents in the hood once a week. Review of the facility's list of residents and diets revealed Resident #71 was nothing by mouth and did not receive food from the kitchen. Review of the policy titled Food and Nutrition Services, dated 09/20/17, revealed the facility was to store food in accordance with professional standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 71 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #62 revealed an admission date of 10/14/22. Diagnoses included fractured right femur. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition. Review of the care plan dated 10/21/22 revealed Resident #62 had pressure related skin alteration injury and/or is at risk/potential risk for pressure related skin alteration injury related to anemia, changes in skin and muscle mass, co-morbidities, general debilitation, immobility, incontinence, reduced bed mobility, requires assistance with skin care, weight loss history and a skin tear from 12/13/22. Interventions included weekly visual skin checks and administer treatments as ordered. Review of the facility's investigation dated 12/13/22, revealed the nurse documented a 5.0 centimeter (cm) by 2.5 cm x 0.1 cm deep skin tear to right lower extremity. Wound care orders were obtained to cleanse with normal saline, pat dry, apply foam dressing to right lower extremity, Mondays, Wednesdays, Fridays and as needed. Review of the physician orders for Resident #62 revealed orders to cleanse the right lower extremity skin tear with normal saline and pat dry, apply foam dressing and change every Monday, Wednesday and Friday and as needed. Review of the Treatment Administration Record (TAR) for December 2022 revealed Resident #62's dressing was documented as completed on 12/14/22 and 12/16/22. Observation on 12/19/22 at 1:10 P.M. of Resident #62 revealed a dressing to her right ankle dated 12/13/22. Observation and interview on 12/19/22 at 1:37 P.M. with Licensed Practical Nurse (LPN) #108 confirmed Resident #62's right ankle dressing was dated 12/13/22. LPN #108 confirmed the dressing was inaccurately signed as completed in the TAR on 12/14/22 and 12/16/22. This deficiency represents non-compliance investigated under Complaint Number OH00137957. Based on staff interview, observations, and review of medical records, the facility failed to ensure the resident's medical records were accurate. This affected two (#25 and #62) of 24 resident records reviewed in the annual survey. The facility census was 84. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 03/12/21 with diagnoses including Alzheimer's disease, pain in right wrist, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had severely impaired cognition. Review of the physician's orders for Resident #25 revealed an order dated 11/29/22 for Tramadol HCL 50 milligrams (mg) one tablet by mouth every six hours as needed for pain and an order dated 12/07/22 for Tramadol HCL 50 mg one tablet by mouth every eight hours for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 72 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Medication Administration Record (MAR) for December 2022 revealed no documented administration for Tramadol HCL Tablet 50 mg on 12/10/22 and 12/12/22 at 12:00 A.M. however, this was administered per the narcotic sheet. On 12/20/22 at 4:00 P.M., it was indicated Resident #25 received Tramadol 50 mg, however, per the narcotic sheet, this medication was not pulled. Interview on 12/21/22 at 2:21 P.M. and 4:29 P.M. and on 12/27/22 at 10:50 A.M. with the Director of Nursing (DON) confirmed staff were not documenting medication administration accurately for Resident #25. Event ID: Facility ID: 366435 If continuation sheet Page 73 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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** 3. Review of the medical record for Resident #189 revealed an admission date of 12/13/22. Diagnoses included encounter for orthopedic aftercare and malignant prostate cancer. Residents Affected - Many Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #189 had intact cognition and the resident had no pressure ulcers, but did have a surgical wound and a skin tear. Review of the skin assessment dated [DATE] revealed Resident #189's left hip had two surgical incision, 13 staples noted to the superior incision and 12 staples noted to the inferior incision. Review of Resident #189's baseline care plan dated 12/13/22 revealed the resident had actual skin alterations with interventions to follow skin care protocols and provide treatments as ordered. Review of the physician orders dated 12/14/22 revealed orders for surgical incision care to cleanse the left hip/thigh surgical incision with normal saline, pat dry, apply border gauze daily and as needed if soiled and dislodged. Observation on 12/19/22 at 11:51 A.M. with Licensed Practical Nurse (LPN) #224 revealed the dressing change to Resident #189's left hip. Two dressings were initially noted, neither were dated or initialed. LPN #224 removed the two old dressings and placed them on Resident #189's bedside table. He then squirted normal saline onto a gauze to cleanse one area, then he squirted the same gauze with more normal saline and cleaned the second area, utilizing the same gauze to cleanse the first area. LPN #224 then dried both areas with a new gauze, but still utilized the same gauze to dry both wounds. LPN #22 applied new dressings and washed his hands, though he did not sanitize the resident's bedside table after contaminating it with two dressings. Interview on 12/19/22 at 12:00 P.M. with LPN #224 confirmed the infection control breaches during the wound care observation, utilizing the same gauze for two separate wound areas and placing the contaminated gauze on the resident's bedside table without sanitizing after. Review of the facility's policy and procedure titled Skin Care Program, dated 11/28/22, revealed upon admission and upon observation of a new skin issue, a resident will have their skin assessed from head to toe by a nurse, each area will be documented and the information will be entered into the electronic charting system. The physician will be notified for orders and representatives will be notified accordingly. It stated a nurse will measure each skin issue weekly and update the plan of care as needed. The facilities policy was to manage the resident's skin issues to avoid development unless unavoidable due to a resident's condition. The policy stated the residents who are admitted to the resident with skin issues will receive the necessary care and treatments to promote healing and prevent infection or new skin issues from developing unless they are clinically unavoidable. This deficiency represents non-compliance investigated under Complaint Number OH00138037. 2. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] with diagnoses including COVID-19. Review of the annual Minimum Data Set (MDS) assessment, dated 10/01/22, revealed Resident #17 had severely impaired cognition and dependent on two staff members for bed mobility and toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 74 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Further review of the medical record revealed Resident #17 had an active infection with COVID-19 and was in isolation precautions from 12/09/22 through 12/19/22. Observation on 12/18/22 at 1:57 P.M. revealed there were signs posted on the door of Resident #17's room indicating Resident #17 was on contact and droplet precautions. State Tested Nursing Assistant (STNA) #228 was observed to exit the room carrying a clear bag full of linens which was taken to the dirty linen room and placed in a barrel with other dirty linen. Interview with STNA #228 on 12/18/22 at 2:06 P.M. verified Resident #17 was in isolation due to an active infection with COVID-19. STNA #228 verified the dirty linens from Resident #17's room had been taken out of the room in a clear, plastic bag and placed in the barrel in the dirty linen room along with the soiled linens from all the other resident's rooms. Observation of the facility's laundry room on 12/18/22 at 3:00 P.M. revealed dirty laundry was sorted into piles to be washed. Numerous red biohazard bags were observed in the corner of the room. Interview with Housekeeping Employee #167 on 12/19/22 at 2:14 P.M. revealed dirty laundry was brought down from the units by nursing staff in barrels to be laundered and all residents on isolation precautions were to have their dirty laundry and linens bagged in separate, red biohazard bags. Housekeeping Employee #167 stated the laundry in the red biohazard bags was washed at the end of the day to keep it separated from other residents laundry. Housekeeping Employee #167 verified all dirty linens in clear, plastic bags were mixed in together to be laundered. Interview with Environmental Director #142 on 12/28/22 at 10:34 A.M. verified laundry for residents in isolation precautions was to be placed in red biohazard bags to be washed at the end of the day so it was not mixed in with other resident's laundry. Based on review of the facility's policy, observations, staff interview, and record review the facility failed to follow a Legionella prevention plan, maintain infection control during wound care for Resident #189, and to ensure laundry was appropriately separated for Resident #17 who had an active COVID-19 infection. This had the potential to affect all 84 residents residing in the facility. Findings include: 1. Review of the facility's Legionella Precautionary Maintenance and Inspection Frequency' form revealed there was equipment and systems to be monitored weekly, monthly, quarterly, and semi-annually. The form was blank. Interview on 12/27/22 at 4:50 P.M. with the Administrator revealed the facility had a water management plan that was to be monitored through the Legionella precautionary maintenance and inspection frequency form. She reported she was unable to find evidence that it was completed at that time but would check again. Electronic communication on 01/04/23 with the Administrator revealed she was unable to find any evidence the facility was monitoring for Legionella per their inspection form. Review of the policy titled Legionella Disease Policy and Procedures, dated 09/01/17, revealed the facility was responsible for developing a water management program team. The facility was to ensure the program is effective through audits and testing as determined by the water management team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 75 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, and staff interviews, the facility failed to maintain kitchen equipment in an operating condition. This had the potential to affect all residents but one resident (#71) identified as eating nothing by mouth. The facility census was 84. Residents Affected - Many Findings include: Observation on 12/18/22 revealed the facility had one main kitchen and four kitchenettes. During a tour of the kitchens with Dietary Director #172 and Assistant Dietary Director #141, they identified multiple essential equipment that was not operating. Observation from 9:30 A.M. to 11:12 A.M. revealed the following concerns: a. In the main kitchen, the freezer had a thick buildup of ice in the right-hand corner. The ice was covering multiple boxes that were not identifiable due to the ice. b. In the Unit A kitchen, the air conditioning was not functioning, the steam table leaked, the dishwasher was down, and the oven did not work. c. In the Unit B kitchen, the dishwasher leaked. d. In the Unit C kitchen, the air conditioning was not functioning, the sandwich station was down, and the steam table had two wells that did not work. e. In the memory care kitchen, the oven was down. Interview on 12/18/22 from 9:30 A.M. to 10:00 A.M. with Assistant Dietary Director #141 confirmed the observation in the freezer, she reported there was a leak in the freezer. Interview on 12/18/22 from 9:30 A.M. to 11:12 A.M. with Dietary Director #172 reported there was more broken down in the kitchen than she could recall during the tour. Dietary Director #172 reported many of the items had been down since before she started four months ago. Dietary Director #172 reported she had submitted the broken items to maintenance, but they had not been fixed. Observation on 12/27/22 from 12:15 P.M. to 1:30 P.M. revealed the freezer still had a thick build up of ice in the right-hand corner, and the boxes of food remained covered in ice. Interview on 12/27/22 from 2:00 P.M. to 2:10 P.M. with Dietary Director #172 confirmed the freezer was still leaking and the ice remained in place. She reported the boxes in the corner contained (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 76 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0908 seafood. Level of Harm - Minimal harm or potential for actual harm Interview on 12/28/22 at 9:45 A.M. with Maintenance Supervisor #106 confirmed the kitchen had a long list of broken equipment. He reported that he was new to the facility and would begin prioritizing the list. He reported the previous system for maintenance requests was unorganized and he was attempting to use a better system to improve prioritization of requests. Residents Affected - Many Review of the maintenance requests from 08/18/22 to 12/18/22 revealed nothing related to the broken items in the kitchen. Review of the facility's list of resident's diets revealed Resident #71 was nothing by mouth and received no food from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 77 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2. Observation on 12/18/22 at 9:53 A.M. revealed there was a small refrigerator with freezer located in the room of Resident #19. The inside of the refrigerator was observed to have a thick layer of a brown, sticky substance located at the bottom. Subsequent observation on 12/27/22 at 10:45 A.M. revealed there continued to be a thick layer of a brown, sticky substance at the bottom of the small refrigerator inside Resident #19's room. Observation on 12/18/22 at 10:30 A.M. revealed there was a small refrigerator with freezer located in the room of Resident #28. The inside of the refrigerator was observed to have a layer of a brown, sticky substance and food debris at the bottom. Interview with the responsible party of Resident #19 on 12/27/22 at 10:45 A.M., inside the resident's room, revealed the refrigerator in the resident's room was always dirty and family frequently had to clean it up. Interview with Environmental Director #142 on 12/28/22 at 10:34 A.M. revealed the facility housekeeping department was responsible for cleaning and maintaining the small refrigerators located in the resident rooms. Environmental Director #142 stated there was not a schedule for cleaning the refrigerators except when a resident left the facility and a new resident was preparing to come in. Environmental Director #142 verified Resident #19 and Resident #28's refrigerators were dirty and needed to be cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00135623. Based on observations, resident representative interview, and staff interview, the facility failed to ensure the memory care unit furniture was maintained in a safe, sanitary, comfortable, and functional manner and failed to maintain clean refrigerators for Resident #19 and Resident #28. This had the potential to affected the 13 residents residing in the memory care unit and affected two (Resident #19 and Resident #28) of three resident refrigerators observed. The facility census was 84. Findings include: 1. Observations on 12/18/22 at 1:23 P.M. and 4:47 P.M., and on 12/19/22 at 12:40 P.M. reveled the furniture in the memory care unit was not maintained in a safe, sanitary, functional, and comfortable manner. Three green chairs were observed with cracked plastic cushions, and one of the green chairs had a white stain. Three orange striped chairs were observed to be faded with multiple unidentifiable stains. The couch was observed with multiple tears on the cushioned seat and the fabric was frayed at the bottom. Interview on 12/19/22 at 12:40 P.M. with Environmental Director #142 confirmed the three green chairs with cracked plastic cushions, one of the green chairs had a white stain, three orange striped chairs were faded with multiple unidentifiable stains and the couch was observed with multiple tears on the cushioned seat and the fabric was frayed at the bottom. Environmental Director #142 reported they did not currently have a steam cleaner. Environmental Director #142 reported they had some excess furniture that could replace the furniture in the memory care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 78 of 79 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 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy Dublin, OH 43017 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on resident representative interview, staff interviews, observations, review of the facility policy, and record review, the facility failed to ensure Resident #38's room was free from pests and maintained in a manner to prevent pests. This affected one (Resident #38) of four residents reviewed for physical environment. The facility census was 84. Residents Affected - Few Findings include: Interview on 12/18/22 at 10:40 A.M. with Resident #38's representative revealed she did not feel they kept Resident #38's room clean. She reported Resident #38 dropped a lot of food, that wasn't swept up and it led to ants. Observation on 12/18/22 at 11:20 A.M. revealed Resident #38 had banana chips and other food debris in her room, she additionally appeared to have ants in her room. Observation on 12/19/22 at 12:35 P.M. revealed Resident #38's representative sweeping in her room. A large number of ants were observed to be in the pile, as well as banana chips and other food debris. Interview with Resident #38's representative at that time revealed she swept every time she visited and there were always ants, she stated she had reported this to staff. Interview on 12/19/22 at 12:37 P.M. with State Tested Nursing Aide (STNA) #187 confirmed there were ants in Resident #38's room. STNA #187 reported Resident #38's representative often swept up food and ants in the room. Interview on 12/19/22 at 12:40 P.M. with Environmental Director #142 revealed he was unaware of any pest concerns in Resident #38's room. He confirmed Resident #38's room needed swept up and reported housekeepers were only in the memory care unit five days a week. Review of the maintenance requests from 08/18/22 to 12/18/22 revealed no concerns related to pests in Resident #38's room. Review of the policy titled Pest Control, dated December 2006, revealed any sighting of insects should be reported to the supervisor per the maintenance repair request form. This deficiency represents non-compliance investigated under Complaint Number OH00135623. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 79 of 79

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

31 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0567GeneralS&S Epotential for harm
F567 - The resident has a right to manage his or her financial affairs
Honor the resident's right to manage his or her financial affairs.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Dpotential for harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0679GeneralS&S Epotential for harm
F679 - Activities
Provide activities to meet all resident's needs.
0684GeneralS&S Epotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0725GeneralS&S Fpotential for harm
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
0730GeneralS&S Fpotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0757GeneralS&S Epotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
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.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0773GeneralS&S Dpotential for harm
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
0803GeneralS&S Fpotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0809GeneralS&S Epotential for harm
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0697SeriousS&S Gactual harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0688GeneralS&S Dpotential for harm
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
0689SeriousS&S Gactual harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0692GeneralS&S Epotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Fpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0921GeneralS&S Epotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0925GeneralS&S Dpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

FAQ · About this visit

Common questions about this visit

What happened during the January 9, 2023 survey of GRAND THE?

This was a inspection survey of GRAND THE on January 9, 2023. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GRAND THE on January 9, 2023?

Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 9, 2023