Health inspection·September 2, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 09/01/23 at 4:02 P.M. of Resident #40's sharps container hanging on the bathroom wall revealed it was overflowing with a used syringe and three lancets. The DON was present during the observation and verified it was both a safety and infection control concern. Review of facility policy titled, Biomedical/Infectious Waste Definition, reviewed 12/28/22, revealed it was the center's policy to utilize the Environmental Protection Agency's (EPA) definitions for waste classification. The center will follow its state and local requirements for waste. Biomedical waste will be disposed of in specified containers to prevent the spread of infection. Further review revealed there are two classifications of infectious waste: Class 3 human blood and blood products and Class 4 used sharps - sharps are considered any article that may cause punctures or cuts. This deficiency is cited as an incidental finding to Complaint Number OH00145727. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 2 of 4 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 09/02/2023 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 - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and facility policy review, the facility failed to ensure a safe environment when sharps containers were not changed when full to prevent overflowing of objects which were a safety control concern. This affected four residents (#40, #59, #65 and #89) and had the potential to affect all 86 residents residing in the facility. Findings included: Interview on 09/01/23 at 3:32 P.M. with Resident #59's family member revealed a concern regarding the sharps container (a hard plastic container for the storage of used sharp items like lancets and needles for safety and infection control by placing the items in the container lid and flipping them down into the container) in the bathroom had been full and overflowing for months and everyone said they couldn't find a key. Resident #59's family member reported it just wasn't sanitary or safe. Observation on 09/01/23 at 3:32 P.M. of Resident #59's sharps container hanging on her bathroom wall overflowing with 10 used lancets and three used glucometer strips on top of the partially closed lid and a used syringe partially sticking out. Interviews on 09/01/23 at 3:37 P.M. with Licensed Practical Nurse (LPN) #247 verified Resident #59's sharp container had been full for a while, at least a few months. She verified Resident #59's husband had brought it to the facility's attention prior to today. LPN #247 revealed she had worked on the unit for six months and had not been able to find a key for the sharps container wall holders to open them and replace the sharps container since working on the unit. Observation on 09/01/23 at 3:41 P.M. of Resident #59's sharps container with the DON who verified the condition of the sharps container was not acceptable due to the used lancets, used glucometer strips, and used syringe were both a safety concern and an infection control concern. Observation on 09/01/23 at 3:48 P.M. of Resident #89's sharps container hanging on the bathroom wall revealed it was overflowing with a used syringe and a used lancet sitting in the lid of the container. The DON was present during the observation and verified it was both a safety and infection control concern. Observation on 09/01/23 at 3:59 P.M. of Resident #65's sharps container hanging on the bathroom wall revealed it was overflowing with a used syringe sitting in the lid of the container. The DON was present during the observation and verified it was both a safety and infection control concern. Observation on 09/01/23 at 4:02 P.M. of Resident #40's sharps container hanging on the bathroom wall revealed it was overflowing with a used syringe and three lancets. The DON was present during the observation and verified it was both a safety and infection control concern. Review of facility policy titled, Biomedical/Infectious Waste Definition, reviewed 12/28/22, revealed it was the center's policy to utilize the Environmental Protection Agency's (EPA) definitions for waste classification. The center will follow its state and local requirements for waste. Biomedical waste will be disposed of in specified containers to prevent the spread of infection. Further review revealed there are two classifications of infectious waste: Class 3 human blood and blood products and Class 4 used sharps - sharps are considered any article that may cause punctures or cuts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 3 of 4 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 09/02/2023 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 This deficiency is cited as an incidental finding to Complaint Number OH00145727. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 4 of 4