Health inspection·January 24, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status. STNA #205 stated she informed LPN #215 sometime after breakfast between 9:00 A.M. to 10:00 A.M. but was not aware of whether the nurse completed an assessment or if she notified the physician. Interview on 01/24/24 at 12:03 P.M. with Licensed Practical Nurse (LPN) #215 revealed she had heard in report of resident having some respiratory cough and congestion issues the last few days and also revealed STNA #205 informed her of a change in condition, changes in mental status and not taking in much oral intake, and shortness of breath. LPN #215 also revealed the resident's daughter was at the facility around 10:00 A.M. and spoke with the nurse about respiratory concerns. LPN #215 assessed Resident #49 and found her oxygen saturations to be in the low 80s and her blood pressure was low. LPN #215 stated she spoke with family and contacted the medical provider who recommended fluids and oxygen. LPN #215 stated she placed the verbal orders in the chart for oxygen and fluids (however, no orders were found for fluids). LPN #215 stated around dinner time, the resident's family had returned to the facility and had concerns of resident's condition not improving and requested a transfer to the hospital. LPN #215 stated the physician was contacted regarding the hospital transfer. LPN #215 could not remember what provider she spoke with during the afternoon call. Interview on 01/24/24 at 2:49 P.M. with Facility Nurse Practitioner (FNP) #220 revealed she was not working on 12/30/23 when Resident #49 had her change in condition. FNP #220 stated staff should contact the on-call provider which reaches a rotation of medical providers who are available on evenings and weekends. FNP #220 stated she had access to all notes and encounters (phone calls) that come through the on-call system and revealed her note from 12/28/23 and 01/07/23 were found and there was evidence of one telephone call (a voicemail) that was left on 12/30/23 at 5:58 P.M. FNP #220 stated the on-call system had no record of any contact from LPN #215 earlier in her shift on 12/30/23. Interview on 01/24/24 at 3:08 P.M. with In-House Supervisor Registered Nurse (ISRN) #225 revealed LPN #215 informed her of the change in Resident #49 on the morning of 12/30/23. ISRN #225 stated she instructed LPN #215 to contact the on-call provider. ISRN #225 stated she was not aware if LPN #215 called the provider and what the recommendations were, but thought she heard something about oxygen and fluids. Interview on 01/24/24 at 4:20 P.M. with the Director of Nursing (DON) revealed the licensed nurses should complete a thorough assessment when a resident was having a change in condition and contact the medical provider or on-call medical provider to provide update and ask for recommendations/guidance. Review of the facility policy titled Change in Condition, dated 04/2013, revealed a change in condition was defined as a deterioration in health of a resident related to a life-threatening condition, alteration in treatment, or a significant change in the resident's condition and clinical status. Life threatening conditions would include infections and respiratory changes. The procedure includes the unit supervisor or charge nurse would notify the Physician of all changes as stated above and any other situations requiring notification and the person doing the notification may document the notification. This deficiency represents non-compliance investigated under Complaint Number OH00149838. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 2 of 7 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 01/24/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Ohio Board of Nursing Scope of Practice for Registered Nurses (RN) and Licensed Practical Nurses (LPN) and the job description for an LPN, and resident and staff interviews, the facility failed to ensure an LPN worked within their scope of practice and requirement of nursing standards during a resident's change in condition. This affected one (Resident #49) of three residents reviewed for a change in condition. The facility census was 93. Finding include: Review of the medical record for Resident #49 revealed an admission date of 01/22/23. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure, atrial fibrillation, heart failure, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired and required set up or clean up assistance from staff for all activities of daily living. Review of the plan of care dated 10/28/23 revealed Resident #49 was at risk for altered health status due to respiratory failure with interventions to monitor for signs and symptoms and report to the doctor including respiratory symptoms, cough, confusion, and fatigue. Review of the respiratory assessments in the Medication Administration Record (MAR) dated 12/2023 revealed Resident #49 had an order for oxygen saturations to obtained three times daily. On 12/30/23, Resident #49's oxygen saturation was at 93% and 96%. Review of the progress note revealed there was no documentation of a change in Resident #49's condition until 6:04 P.M. on 12/30/23. The progress note dated 12/30/23 at 6:04 P.M. written by LPN #215 revealed Resident #49's family came to nurse and asked for resident to be assessed as they felt something was wrong. Resident #49's vital signs were taken and oxygen saturation was at 82%. The nurse applied oxygen and it brought it up a little bit, Resident #49 was still lethargic and the family was insisting Resident #49 be transferred to the hospital. The nurse offered to consult the on-call medical provider and the family declined. A message was left with the on-call medical provider to notify of the transfer. Review of the physician orders for 12/30/23 at 6:00 P.M. revealed a verbal order was given to the nurse for oxygen at two liters continuous as needed to maintain oxygen saturations above 92%. The order did not state who the order was obtained by. The facility's Nurse Practitioner signed the order on 01/05/23 at 9:53 A.M. and there was no mention of which provider actually instructed the nurse to begin oxygen as the Nurse Practitioner was not on call on 12/30/23. Review of the hospital record from the emergency department dated 12/30/23 revealed Resident #49 was brought in around 6:00 P.M. for shortness of breath and had also complained of orthopnea and chest pain. The family also reported to intermittent confusion. The hospital note revealed Emergency Medical Services (EMS) responded to Resident #49 at the facility and found the resident's oxygen saturations to be in the 80s. EMS provided oxygen and breathing treatments and brought Resident #49 to the hospital. Resident #49 arrived to the hospital and found to have atrial fibrillation with rapid ventricular rate (RVR) and required six liters of oxygen and then transitioned to BiPap. Resident #49 was also found to be positive for influenza A and a chest x-ray showed bilateral opacities with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 3 of 7 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 01/24/2024 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 0726 appearance suspicious for multifocal pneumonia with underlying chronic lung disease. Level of Harm - Minimal harm or potential for actual harm Interview on 01/24/24 from 10:45 A.M. with RN #201 revealed if a resident's oxygen was low and drops below 90%, she would start the resident on oxygen, take vital signs and contact the medical provider for assistance and possible orders. RN #201 stated she would do a recheck and keep the provider updated on whether the symptoms were improving. Residents Affected - Few Interview on 01/24/24 at 10:58 A.M. with Resident #49 revealed the nurse (LPN #215) provided no assistance to feel better on the day she went to the hospital (12/30/23). Resident #49 stated the nurse (LPN #215) asked how she was feeling but did not provide adequate medical care. Interview on 01/24/24 at 11:06 A.M. with State Tested Nursing Aide (STNA) #205 verified she was assigned to provide care to Resident #49 during the day on 12/30/23. STNA #205 stated she noticed Resident #49 was acting off the morning of 12/30/23. Resident #49 was laying in bed, had difficulty completing activities of daily living she normally could complete, and was having changes in her mental status. STNA #205 stated she informed LPN #215 sometime after breakfast between 9:00 A.M. to 10:00 A.M. but was not aware of whether the nurse completed an assessment or what the assessment entailed. Interview on 01/24/24 at 1:12 P.M. with RN #208 revealed if a resident was having shortness of breath with oxygen saturations below 92%, she would contact the physician and place the resident on oxygen. RN #208 stated she would continue to check vital signs at least every hour until symptoms stabilize or the resident goes out to the hospital. RN #208 stated on 12/30/23, she was working, and denied being informed of concerns related to Resident #49's health. RN #209 stated she was not asked to assess Resident #49 and was not asked for any assistance regarding care for Resident #49 by LPN #215. Interview on 01/24/24 at 12:03 P.M. with LPN #215 stated she had heard in morning report of Resident #49 having some respiratory cough and congestion issues the last few days. LPN #215 verified STNA #205 informed her of Resident #49 having a change in condition, changes in mental status, not taking in much oral intake, and shortness of breath. LPN #215 also stated Resident #49's daughter was at the facility around 10:00 A.M. and spoke with the nurse about respiratory concerns. LPN #215 stated she assessed Resident #49 and found her oxygen saturations to be in the low 80s and her blood pressure was low. LPN #215 stated she spoke with the family and contacted the medical provider who recommended fluids and oxygen. LPN #215 stated while rechecking Resident #49's vital signs, she noticed improvement. However, LPN #215 could not remember what the vital signs were upon recheck (thought they were around 87-94%) and also could not remember exactly how often she completed rechecks throughout the day, but revealed it was likely every 60 to 90 minutes. LPN #215 stated around dinner time, the resident's family had returned to the facility and had concerns of Resident #49's condition not improving and requested Resident #49 to be transferred to the hospital. LPN #215 stated she assessed the resident and informed the nurse supervisor of the family wishes for a transfer to the hospital. Interview on 01/24/24 at 3:08 P.M. with In-House Supervisor Registered Nurse (ISRN) #225 revealed LPN #215 informed her of the change in Resident #49's condition on the morning of 12/30/23 and she instructed her to contact the on call provider. ISRN #225 stated she had not heard updates on what the on-call provider ordered and did not hear back until around 6:00 P.M. when LPN #215 informed her Resident #49 did not look good. ISRN #225 stated the bedside LPN completed all assessments for Resident #49 and denied ever assessing Resident #49 or checking vitals herself. ISRN #225 stated her expectation of staff was to reassess a resident having changes in condition regularly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 4 of 7 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 01/24/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Interview on 01/24/24 at 4:20 P.M. with the Director of Nursing (DON) revealed the licensed nurses should complete a thorough assessment when a resident is having a change in condition and contact the medical provider or on-call medical provider for recommendations. The DON was also unaware of the scope of practice between an LPN and a RN in regards to assessments without RN oversite. The DON stated an In-House Supervisor Registered Nurse could also do assessments. Residents Affected - Few Review of the Ohio Board of Nursing Scope of Practice for RNs and LPNs dated 10/2019 revealed it is within the LPN scope of practice and a requirement of nursing standards that LPNs accurately and timely document their observations of the patient, the nursing care they provide, and the patient's response to the nursing care. Whether it is an initial or ongoing assessment of a patient, the LPN's role is the same, which is to collect only objective and subjective data. The assimilation and analysis of the data and the formulation of the plan of nursing care is always the RN's responsibility. Review of the job description for an LPN revealed the LPN was responsible for providing and coordinating care and assessing needs. This would include obtaining reports, collecting data and identifying problems, and observe signs and symptoms. The job description does not include completing ongoing assessments and making medical determinations without oversite of an RN. This deficiency represents non-compliance investigated under Complaint Number OH00149838. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 5 of 7 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 01/24/2024 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 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. Based on record review, review of the Ohio Board of Nursing Scope of Practice for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), and staff interviews, the facility failed to ensure there was complete and accurate documentation of a resident's change in condition in the medical record. This affected one (Resident #49) of three residents reviewed for change in condition. The facility census was 93. Finding include: Review of the medical record for Resident #49 revealed an admission date of 01/22/23. Diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, respiratory failure, atrial fibrillation, heart failure, and anxiety. Review of the respiratory assessments in the Medication Administration Record (MAR) dated 12/2023 revealed Resident #49 had an order for oxygen saturations to obtained three times daily. On 12/30/23, Resident #49's oxygen saturation was at 93% and 96%. There was no other documentation of Resident #49's oxygen saturations that were taken by Licensed Practical Nurse (LPN) #215 on 12/30/23 on the MAR. Review of the progress note revealed there was no documentation of a change in Resident #49's condition until 6:04 P.M. on 12/30/23. The progress note did not address Resident #49's change in condition that was reported in the morning report, by State Tested Nursing Aide (STNA) #205 and the Resident #49's family member in the morning. The progress not did not reflect an attempt to call the physician in the morning. The progress note dated 12/30/23 at 6:04 P.M. written by LPN #215 revealed Resident #49's family came to nurse and asked for resident to be assessed as they felt something was wrong. Resident #49's vital signs were taken and oxygen saturation was at 82%. The nurse applied oxygen and it brought it up a little bit. Resident #49 was still lethargic and the family was insisting Resident #49 be transferred to the hospital. The nurse offered to consult the on-call medical provider and the family declined. A message was left with the on-call medical provider to notify of the transfer. Review of the physician orders for 12/30/23 at 6:00 P.M. revealed a verbal order was given to the nurse for oxygen at two liters continuous as needed to maintain oxygen saturations above 92%. The order did not state who the order was obtained by and did not include anything about fluid intake. The facility's Nurse Practitioner signed the order on 01/05/23 at 9:53 A.M. and there was no mention of which provider actually instructed the nurse to begin oxygen as the Nurse Practitioner was not on call on 12/30/23. Interview on 01/24/24 from 10:45 A.M. with Registered Nurse (RN) #201 stated the nursing assessments and contact with the provider should be documented in the medical record including any recommendations or treatments. Interview on 01/24/24 at 11:06 A.M. with State Tested Nursing Aide (STNA) #205 verified she was assigned to provide care to Resident #49 during the day on 12/30/23. STNA #205 stated she noticed Resident #49 was acting off the morning of 12/30/23. Resident #49 was laying in bed, had difficulty completing activities of daily living she normally could complete, and was having changes in her mental status. STNA #205 stated she informed LPN #215 sometime after breakfast between 9:00 A.M. to 10:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 6 of 7 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 01/24/2024 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 0842 A.M. but was not aware of whether the nurse completed an assessment or if she notified the physician. Level of Harm - Minimal harm or potential for actual harm Interview on 01/24/24 at 12:03 P.M. with LPN #215 stated she had heard in morning report of Resident #49 having some respiratory cough and congestion issues the last few days. LPN #215 verified STNA #205 informed her in the morning that Resident #49 was having a change in condition, changes in mental status, not taking in much oral intake, and shortness of breath. LPN #215 also stated Resident #49's daughter was at the facility around 10:00 A.M. and spoke with the nurse about respiratory concerns. LPN #215 stated she assessed Resident #49 and found her oxygen saturations to be in the low 80s and her blood pressure was low. LPN #215 stated she spoke with the family and contacted the medical provider who recommended fluids and oxygen. LPN #215 stated while rechecking Resident #49's vital signs, she noticed improvement. However, LPN #215 could not remember what the vital signs were upon recheck (thought they were around 87-94%) and also could not remember exactly how often she completed rechecks throughout the day, but revealed it was likely every 60 to 90 minutes. LPN #215 stated around dinner time, the resident's family had returned to the facility and had concerns of Resident #49's condition not improving and requested Resident #49 to be transferred to the hospital. LPN #215 stated she assessed the resident and informed the nurse supervisor of the family wishes for a transfer to the hospital. Residents Affected - Few Interview on 01/24/24 at 3:08 P.M. with In-House Supervisor Registered Nurse (ISRN) #225 stated her expectation of staff was to reassess a resident having changes in condition regularly and those assessments should be documented as well as when the change in condition was identified and steps taken to care for resident including conversations with medical providers and their recommendations. Interview on 01/24/24 at 4:20 P.M. with the Director of Nursing (DON) confirmed the facility had no process in place of how staff should document changes in condition including what to document and where. The DON stated it could be documented in a progress note, an assessment, in the MAR, an order, or other means and also did not have expectations for staff on what information should be documented. The DON declined to confirm that facility had no evidence or documentation related to a call made to the physician prior to 5:58 P.M. The DON did confirm documentation with the medical provider was most important. Review of the Ohio Board of Nursing Scope of Practice for RNs and LPNs dated 10/2019 revealed it is within the LPN scope of practice and a requirement of nursing standards that LPNs accurately and timely document their observations of the patient, the nursing care they provide, and the patient's response to the nursing care. Whether it is an initial or ongoing assessment of a patient, the LPN's role is the same, which is to collect only objective and subjective data. The assimilation and analysis of the data and the formulation of the plan of nursing care is always the RN's responsibility. This deficiency represents non-compliance investigated under Complaint Number OH00149838. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366446 If continuation sheet Page 7 of 7