Health inspection·December 28, 2022

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** 3. Review of the medical record for Resident #85 revealed an admission date of 09/29/21. The resident had diagnoses including dementia, chronic kidney disease, and hypertension. Residents Affected - Few Review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. The resident had no rejection of care identified. The resident required limited assistance from one staff with personal hygiene. Review of the plan of care revealed Resident #85 required one to two person assistance with activities of daily living. The goal was for activities of daily living needs to be met. Interventions included grooming (nails/shave/hair) assistance needed of one staff. Observations on 12/19/22 at 10:36 A.M. and 3:30 P.M. and 12/20/22 at 9:49 A.M. revealed Resident #85 to be up in his wheelchair. He had a moderate growth of white facial hair. Observations on 12/20/22 at 2:20 P.M. revealed the resident to be in a wheelchair in his room visiting with family. He continued to have a moderate growth of white facial hair. Interview with his daughter revealed he would want to be shaved routinely. She stated she brought in good razors for the facility to use but it depended on who was working as to whether he got shaved or not. Interview with the Director of Nursing on 12/20/22 at 3:40 P.M. confirmed the resident had a growth of facial hair. She stated he should be shaved on shower days. It was determined his shower days were Monday and Thursday. Interview with the Director of Nursing on 12/20/22 at 4:05 P.M. revealed she spoke with the nursing assistant who provided care for Resident #85 on 12/19/22 (Monday) and it was determined a shower was not provided as scheduled. She stated the nursing assistant did not have a good reason for why the shower/shaving was not provided. Based on record review, observation, resident interview, family interview, and staff interview, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed with showers, nail care, and shaving of unwanted facial hair. This affected three (Resident #49, #85, and #88) of five residents reviewed for Activities of Daily Living (ADLs). The facility's census was 86. Findings include: 1. A review of Resident #49's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, Parkinson's disease, and adult failure to thrive. A review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was usually able to make herself understood. Her cognition was severely impaired. She was not indicated to have displayed any behaviors or reject care during the seven day assessment period. She was totally dependent on one for personal hygiene and was dependent on one for bathing. A review of Resident #49's care plans revealed she had a care plan in place for requiring assistance with ADL's and could be at risk for developing complications associated with decreased ADL self (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 2 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 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 - Few performance. Her goal was for all of her ADL needs to be met. The interventions included providing total care by one for grooming, which included nail care. A review of Resident #49's bathing documentation under the task tab of the electronic health record (EHR) revealed the resident was last documented as receiving an unspecified bathing activity on 12/26/22. Nails were indicated to have been assessed and nail care was indicated to have been provided on 12/26/22. On 12/20/22 at 11:06 A.M., an interview with Resident #49's family revealed they had concerns with the resident not receiving nail care as she should. The family member reported they were painted but not always clipped. On 12/28/22 at 8:50 A.M., an observation of Resident #49 noted her fingernails on both her hands were long and in need of being trimmed. They were painted orange with nail polish, but there was a 1/4 to a 1/2 inch of unpainted nails where the nail had grown out since they were last painted. The resident was awake and responded to questions asked. She was asked about her fingernails and reported they needed to be cut. She stated the facility staff painted them but did not cut them. It was not her preference to allow her nails to grow out and preferred them to be kept short. On 12/28/22 at 10:10 A.M., an interview with State Tested Nursing Assistant (STNA) #117 revealed Resident #49 was totally dependent on staff for personal care. Nail care was to be provided on shower days but could be done anytime a resident was noted to have long nails that needed cut. She reported the resident was compliant with nail care and she had not known her to refuse to have her nails trimmed. She stated the resident was not able to voice her preference on her nail length so they just kept them short so she would not scratch herself. She was asked to check the resident's nails and confirmed they were long and in need of being trimmed. The resident commented they were long when STNA #117 was checking them. STNA #117 reported the resident was due for a shower on that day and they would trim her nails for her when her shower was completed. On 12/28/22 at 1:30 P.M., a follow up observation of Resident #49 noted her to be up in a Broda chair in a common area. She had her nails trimmed and was in the process of receiving nail care from the activity staff. Her nails were short and no longer extended past the end of her digits (fingers/ thumbs). 2. A review of Resident #88's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, chronic ischemic heart disease, obesity and depression. A review of Resident #88's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues. She was able to make herself understood and was able to understand others. She was cognitively intact and was not known to display any behaviors or reject care. Bathing activity was not indicated to have occurred during the seven day assessment period. She required an extensive assist of one for transfers and dressing. She required a limited assist of one for personal hygiene. A review of Resident #88's care plans revealed she may require assistance with ADL's and may be at risk for developing complications associated with decreased ADL self performance. Her goal was for her ADL needs to be met. The interventions included providing the resident with the physical assist of one for bathing. Her care plan indicated it was the resident's preference to receive a shower as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 3 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 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 her bathing activity of choice. Level of Harm - Minimal harm or potential for actual harm A review of the shower schedule for Resident #88's hall revealed she was to be showered on Tuesdays and Fridays by the evening shift. All the residents on that list were receiving two showers each week with the exception of one resident who was getting three a week. Residents Affected - Few A review of Resident #88's bathing documentation under the task tab of the EHR revealed during the past 30 days (11/28/22 through 12/26/22), the resident was only documented as having received one bathing activity out of eight opportunities on her scheduled shower days (Tuesdays/Fridays) during that 30 day period. The bathing activity was not specified as to what type of bathing activity had been provided. It only asked if the resident had received a tub bath, shower, bed bath etc. and the staff member would just document yes or no. Bathing activities were not documented as having taken place on 12/02/22, 12/06/22, 12/09/22, 12/13/22, 12/16/22, 12/20/22, or 12/23/22. They did document a bathing activity had been provided on six other occasions that was not on her scheduled shower day but did not specify if that bathing activity was a shower or a partial bed bath as part of A.M. or P.M. care. On 12/27/22 at 10:30 A.M., an interview with Resident #88 revealed the facility staff did not give her showers when scheduled. She stated if she received a shower it was because her daughter was in and gave her a shower. She indicated her daughter did not mind doing it but only did it because she knew the resident would not get one otherwise. If the facility provided her with showers, she stated the daughter would not feel the need to do them. Bathing documentation in the past 30 days was reviewed with the resident at the time of the interview. She denied she had been showered on the six days a bathing activity was documented as having been provided on her non-scheduled shower days. She stated sometimes they sat her up with a wash basin and she washed herself up with that. She suspected that was what staff were documenting when indicating a bathing activity took place on her non-scheduled shower days. On 12/27/22 at 10:55 A.M., an interview with STNA #123 revealed Resident #88 needed assistance of one with ADL care. She reported the resident was scheduled to receive afternoon showers, so her showers were done by the night shift. She was not sure what her scheduled days were since they were not done on her shift. The resident was good about telling staff when her shower was due. The resident was compliant with ADL care and was not one to refuse care. Showers were documented in the computer when completed, but they also had shower sheets staff fill out and turn in to the nurse to be signed off. STNA #123 stated they only documented the level of assistance a resident needed with the bathing activity and it did not have them indicate if a tub bath, bed bath, or shower was provided. She reported the resident wanted showers on her scheduled days. The resident's daughter was known to come in and shower the resident when the resident wanted to be showered. On 12/27/22 at 11:08 A.M., an interview with Resident #88's family member revealed her sister and niece were the ones who provided the resident with showers when they were visiting. She stated the resident previously lived with them and they had a comfort level with showering her as they did it before. She reported the resident was not receiving her showers as scheduled, which was why the family was showering her at times when they visited the resident. It was not the family's preference to take part in her care or to shower her when visiting. They just did it because they knew the resident was not receiving them as she should have been or as often as she wanted. On 12/27/22 at 11:40 A.M., an interview with the Director of Nursing (DON) revealed a resident's preferences for bathing was asked upon admission by the admitting nurse. Every resident was scheduled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 4 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to be showered at least twice a week on the shower schedule, but could receive more if requested. She acknowledged Resident #88's bathing documentation did not show she was receiving showers twice a week on Tuesdays and Fridays as scheduled. She stated she would look to see if they had any other documented evidence of showers being given to the resident on her scheduled shower days. On 12/27/22 at 2:10 P.M., a follow up interview with the DON revealed she was only able to find documented evidence on a paper shower sheet of a shower being provided on 12/20/22. The shower sheet revealed the resident did receive a shower on that date, but it was provided to her by her family. She was not able to find paper shower sheets showing evidence of the resident receiving showers on 12/02/22, 12/09/22, 12/13/22, 12/16,22 or 12/23/22. She thought the dates when a bathing activity was documented as having been completed on the resident's non-scheduled shower days (12/03/22, 12/08/22, 12/14/22, 12/15/22, 12/17/22, and 12/24/22) were dates when the resident was given a shower by facility staff after the resident had been waiting to receive it from her family. She alleged the resident would want to wait until her family came in before allowing her shower to be completed. She acknowledged the bathing documentation they had, did not provide evidence showers were given on those dates to dispute the resident's reports of not getting two showers a week as scheduled. She confirmed since the bathing documentation did not specify the type of bathing activity that was provided, they could not prove showers were being provided. Event ID: Facility ID: 366446 If continuation sheet Page 5 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 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 Based on record review, observations, and staff interview, the facility failed to ensure skin prevention interventions were implemented for a resident with a history of pressure ulcers. This affected one (Resident #17) of four residents reviewed for pressure ulcers. The facility's census was 86. Residents Affected - Few Findings include: Review of the medical record for Resident #17 revealed an admission date of 11/02/20. The resident had diagnoses including hemiplegia following cerebral infarction, chronic kidney disease stage 3, anxiety disorder, and hypertension. Review of a Minimum Data Set assessment completed 11/09/22 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The resident required extensive assistance from two staff with bed mobility, transfers, and walking. It indicated the resident had a stage III pressure ulcer that was not present upon admission. Review of the plan of care revealed the resident was at risk for alterations in skin integrity related to reduced strength and endurance, impaired gait, altered sensation, pain, diminished cognition, decreased mobility, medication use, and incontinence. The goal was no new areas of skin breakdown. Interventions included pressure reducing cushion. Review of pressure ulcer risk assessments completed on 09/11/22, 10/20/22, and 11/09/22 indicated the resident was at risk for the development of pressure ulcers. Review of physician's orders revealed on 11/03/20 a pressure reduction cushion to the chair every shift was ordered. Review of the Treatment Administration Record for December 2022 revealed the pressure reduction cushion to the chair every shift was documented as done every shift from 12/01/22 to 12/19/22. Observation on 12/20/22 at 9:27 A.M. revealed Resident #17 was seated in a recliner chair in his room. The resident was complaining of his bottom hurting from sitting in the chair. On 12/20/22 at 9:28 A.M. Licensed Practical Nurse (LPN) #110 stated she was aware Resident #17 was having pain and had given him Tylenol at 8:15 A.M. LPN #110 stated he currently had a pressure reducing cushion in his recliner. She stated the family wanted the resident up in the chair for meals. Observation and interview on 12/20/22 at 9:30 A.M. with the Director of Nursing (DON) confirmed Resident #17 did not have a pressure reducing cushion in the recliner he was sitting in, and should have. Resident #17 was assisted to bed. Observations revealed a small area of excoriation of the buttocks that was not open. At 9:40 A.M. Resident #17 said his bottom felt better since being in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 6 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure a resident's fall prevention interventions were in place as per the plan of care. This affected one (Resident #33) of four residents reviewed for falls. The facility's census was 86. Findings include: A review of Resident #33's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included adult onset diabetes mellitus, hypertension, congestive heart failure, anemia and age related osteoporosis. A review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make herself understood and was able to understand others. Her cognition was moderately impaired and she was known to have both hallucinations and delusions. She was not known to reject care. She required a limited assist of one for bed mobility, transfers, locomotion on the unit, and toilet use. Resident #33 required supervision with set up help for locomotion off the unit. Ambulation was not indicated to have occurred and a wheelchair was listed as a mobility device used. She was not identified as having had any falls since her prior assessment. A review of Resident #33's nurses' progress notes revealed a nurse's note dated 03/07/21 at 8:49 P.M. that indicated at 6:40 P.M. staff heard the resident yelling from her room. They walked into her room and observed her lying on the floor next to the bed sitting on a floor mat with her wheelchair sitting next to door. They assisted the resident to her wheelchair with the assist of four using a gait belt. The resident had no obvious signs of injury as a result of the fall. Anti-rollbacks were added to her wheelchair as the new intervention to prevent the reoccurrence of falls. A review of Resident #33's care plan revealed she was at risk for falls secondary to reduced strength/endurance, impaired gait/ balance, diminished cognition and safety awareness. The goal was to minimize potential risk factors related to falls. Her interventions included the use of anti-rollbacks (a device applied to a wheelchair with metal rods that engaged the wheels when pressure was lifted from the seat preventing the wheelchair from moving backwards when the resident stood up from the wheelchair) to her wheelchair. On 12/19/22 at 4:12 P.M., an observation of Resident #33 noted her to be up in her wheelchair. The wheelchair had part of an anti-rollback system to the back of the wheelchair that was missing some parts and not able to engage wheels as intended. There was only one metal rod noted on the right side of the wheelchair but it was not positioned correctly to be able to engage the wheel of the wheelchair in the event the resident attempted to stand unassisted. The metal rod was missing to the left side of the wheelchair and there was no rod to engage the left wheel at all. On 12/20/22 at 3:39 P.M. an interview with Licensed Practical Nurse (LPN) #106 revealed Resident #33 was at risk for falls. LPN #106 reported Resident #33 had fallen in the past, but did not recall her having any recent falls. LPN #106 verified Resident #33 had an intervention in place for the use of a anti-rollback device to her wheelchair. Interview and observation on 12/20/22 at 3:45 P.M. revealed Resident #33 was receiving therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 7 of 8 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 366446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadow Grove Transitional Care 5919 Blue Star Drive Grove City, OH 43123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few services. Physical Therapy Assistant (PTA) #200 and Physical Therapist (PT) #205 reported they would have to have Resident #33 stand up to see if the anti-rollback device was in proper working order. They did not want to confirm parts were missing as there were different devices on the market and they were not sure if the kind the resident had required the metal rods to engage the wheels. PTA #200 and PT #205 assisted Resident #33 to a standing position and verified the wheelchair's anti-rollback device did not engage the wheels, preventing it from moving back when the resident stood. PTA #200 and PT #205 acknowledged there was a missing metal rod on the left side of the device and the metal rod on the right side was not properly positioned to be able to engage the right wheel rendering it ineffective. PTA #200 and PT #205 stated they would have maintenance replace the missing parts to get it in proper working order. A review of the facility's Fall Management policy dated 10/17/16 revealed it was the intention of the facility to promote programs geared to improving mobility, stamina, and reduce the risk of falls through a comprehensive, interdisciplinary process of assessment, care plan development and implementation with ongoing monitoring and review. Each resident would be assessed throughout the course of treatment for different parameters such as safety awareness, fall history, mobility, medications, or predisposing health conditions that may contribute to fall risk. An interdisciplinary plan of care would be developed, implemented, reviewed, and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. Residents who experienced a fall would have their immediate needs quickly assessed and responded to. A plan would be identified and implemented as necessary to protect the resident and/ or others from recurrence. New fall reduction interventions were to be communicated to care givers as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 8 of 8