Inspection·July 28, 2022

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 07/26/22 at 2:30 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 still was holding the plastic puzzle but not engaging with it. At the time of the observation, bingo was occurring, but Resident #13 had not been invited and was not participating. No staff approached Resident #13 to assist her with the puzzle. On 07/27/22 at 3:15 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 sitting in the chair sleeping. At the time of the observation, a music performance was occurring, but Resident #13 was not in attendance. On 07/26/22 at 4:35 P.M., Resident #13 was observed to be in a sitting in the common area adjacent to the 400-hall dining area and nurse's station. Resident #13 was still sitting in same chair, sleeping, and leaning to the left. Interview with the Activities Director #6 on 07/27/22 at 2:30 P.M. revealed she normally does 1:1 visits with Resident #30 twice per week when she had the time. Activities Director #6 also confirmed the activities logs for Resident #13 showed very little evidence of activity participation in June and no documentation in July. Activities Director #6 stated she was getting used to the new documentation system and she was the only activities staff at the time. Interview with the Administrator on 07/28/22 at 10:00 A.M. revealed another Activity Staff was in the process of being hired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of Medscape guidance, and staff interview, the facility failed to provide proper justification for the use of psychotropic medications. This affected one (Resident #14) of five residents reviewed for unnecessary medications. The facility census was 76. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, anxiety disorder, anorexia, and mood disorder. Review of the Minimum Data Set (MDS) assessment, dated 05/06/22, revealed Resident #14's cognitive status was not assessed due to her inability to answer the questions appropriately. Review of Resident #14's medical records revealed she had a physician order for Zyprexa (antipsychotic) five milligrams (mg) with the justification for the medication being for the diagnoses of agitation and psychosis. Neither of those diagnoses were listed in Resident #14's diagnoses list. Interview with Director of Nursing (DON) on 07/27/22 at 2:30 P.M. confirmed the current diagnoses listed for her Zyprexa were not appropriate for the use of the medication. The DON stated she would have to review her diagnoses and other medical records to determine what the actual justification would be for Zyprexa. No proper justification from the pharmacy or physician was found for the physician order of Zyprexa. Review of the Medscape guidance found at medscape.com revealed Zyprexa is used for Bipolar Mania, Agitation-Associated with Schizophrenia and Bipolar Mania, Bipolar depression, and Schizophrenia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 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 observation, medical record review, review of Medscape guidance and U.S. Pharmacist guidance, and staff interview, the facility failed to ensure a medication error rate below five percent (%). Out of 32 opportunities, there were three errors to equal an error rate of 9.4%. This affected one (Residents (#5) of three residents observed for medication administration. The facility census was 76. Residents Affected - Few Findings include: Review of the medical record for Resident #5 revealed an admission date of 08/09/22. Diagnoses included high blood pressure, Alzheimer's disease, dementia, osteoporosis, tremors, chronic kidney disease, and kidney transplant status. Review of the Minimum Data Set (MDS) assessment, dated 07/11/22, revealed Resident #5 had adequate vision and corrective lenses. Review of Resident #5's care plan dated 07/25/22, revealed the resident may require assistance with activities of daily living (ADL) and may be at risk of developing complications associated with decreased ADL self performance with interventions for glasses. Review of Resident #5's physician orders revealed orders for Systane Balance Solution 0.6% with instructions to administer one drop in both eyes four times daily for dry eyes, Dorzolamide HCl-Timolol Mal Solution 22.3-6.8 milligrams (mg) /milliliter (ml) with instructions to instill one drop in left eye two times a day for glaucoma, and Brimonidine Tartrate Solution 0.2 % with instructions to instill one drop in left eye two times a day for glaucoma. The Dorzolamide and Brimonide medications were due upon rising and at bedtime, the Systane was due upon rising, lunch, dinner, and bedtime. Observation on 07/27/22 at 8:59 A.M. with Licensed Practical Nurse (LPN) #628 revealed she administered Resident #5's three separate eye drops within a one minute period. At 8:59 A.M. one drop of the Brimonide was administered to the left eye, at 9:00 A.M. one drop of the Dorzolamide medication was administered to the left eye, and at 9:00 A.M. one drop of the Systane medication was administered to both eyes. Interview on 07/27/22 at 9:11 A.M. with LPN #628 revealed there was no specified time on the eye drop order so it was acceptable to give them without a waiting period in between. She stated she made sure the whole eye was saturated with the drop, but if the order specified to wait between drops she would do that. Subsequent interview on 07/27/22 at 9:15 A.M. with LPN #628 revealed the time to wait between eye drops was five minutes and she confirmed she did not wait that time frame to administer the eye drops to Resident #5. Review of the Medscape guidance found at medscape.com revealed if administering Brimonidine Tartrate and another opthalmic product is being administered, wait five minutes between instilling eye drops. Review of the U.S. Pharmacist guidance titled How to Use Eye Drops Properly, dated 03/14/03, found at https://www.uspharmacist.com/article/how-to-use-eye-drops-properly, stated if another drop of eye medication is needed, wait at least five to 10 minutes before administering the second eye drop so the first drop will not be washed out of the eye. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 07/27/22 at 8:02 A.M. with Registered Nurse (RN) #82 of the 200 hall medication storage room revealed the following concerns: an opened and undated bottle of Gabapentin liquid (treats nerve pain) with Resident #34's name on it, an opened vial of Tuberculin Purified Protein Derivative (PPD) that was undated, and an opened and undated bottle of Lorazepam liquid (treats anxiety) for Resident #5. Interview on 07/27/22 at 8:02 A.M. with Registered Nurse (RN) #82 confirmed the opened and undated medications in the 200 hall medication storage room. 3. Observation on 07/27/22 at 9:20 A.M. with RN #82 of the 100 hall medication storage room revealed the following concerns: 18 Diphenhydramine 25 milligram (mg) bottles expired May 2022, 10 Vitamin E 180 mg bottles expired May 2022, three Carbamide Peroxide ear drop bottles expired May 2022, and one Influenza Vaccine expired 06/07/22. Interview on 07/27/22 at 9:20 A.M. with RN #82 confirmed the expired medications in the 100 hall medication storage room. Review of the facility's list of medications used by residents revealed Residents #18, #28, and #61 received diphenhydramine 25 milligrams (mg), Resident #15, #125, #224, #225, #226, #274, and #276 received a Tuberculosis skin test test in the last three months, and Residents #1, #4, #5, #8, #36, #38, #50, and #54 received an influenza vaccine in the last six months. The facility identified there were no residents who received the Vitamin E 180 mg or the carbamide peroxide ear drops. Review of the facility's policy titled Medication Storage, dated 07/23/19, revealed outdated medications are immediately removed from stock and disposed of accordingly. Based on review of the facility's policy, review of the Bristol [NAME] Squibb Prescribing Information document, observations, staff and staff interviews, and record review, the facility failed to properly store medications in a safe manner. This affected three of four medication carts and two of four medication rooms observed for medication storage. This affected one resident (#18) who was allowed to self-administer some of her medications. This had the potential to affect five residents who were identified by the facility as being cognitively impaired and at risk for wandering. Additionally, this had the potential to affect three residents (#18, #28, and #61) who received diphenhydramine 25 milligrams (mg), seven residents (#15, #125, #224, #225, #226, #274, and #276) who received a Tuberculosis skin test test in the last three months, and eight Residents (#1, #4, #5, #8, #36, #38, #50, #54) who received an influenza vaccine in the last six months. The facility identified there were no residents who received the Vitamin E 180 mg or the carbamide peroxide ear drops. The facility census was 76. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 11/06/21 and diagnoses including multiple myeloma, diabetes mellitus, and chronic pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had no communication impairment, was cognitively intact, and had no behaviors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Review of the physician's orders for Resident #18 revealed there were current orders for pomalidomide sodium (treats cancer) three milligram capsules to be given once per day for 21 days. There was also an order for Tylenol 325 milligram tablets to be given three times daily. Resident #18 did not have a physician order for self-administration of any medication and did not specify what medications could be stored at bedside. Residents Affected - Some Review of the self-administration skills assessment dated [DATE] revealed Resident #18 was given permission to self-administer pantoprazole (treats gastroesophageal reflux disease), Fibercon (supplement), cranberry tablet (supplement), and the pomalidomide sodium medication. The assessment also revealed the resident had demonstrated the proper way to secure the medication. The assessment did not specify how the medications were to be stored in the resident's room. Review of the clinical plan of care last revised on 07/20/22 revealed Resident #18 self-administered some of her medications. The plan of care did not provide details about what medications would be self-administered and how they would be stored in the resident's room. Review of the self-administration skills assessment dated [DATE] revealed Resident #18 was given permission to self-administer medications however it did not specify which medications could be self-administered. The assessment also revealed Resident #18 had demonstrated the proper way to secure the medication. Again, it did not specify how the medications should be stored in the resident's room. Observation and interview on 07/25/22 at 10:40 A.M. with Resident #18 revealed an observation of the top part of an open drawer her nightstand revealed a small yellow plastic bag that contained medications. Resident #18 stated the medications were her chemotherapy drug (pomalidomide sodium). Resident #18 stated she had permission to keep it in her medication in her room because no one else was allowed to touch it since it cost $1,000 per pill and could not be handled by anyone but herself. In addition, there were were two round white pills sitting in a clear plastic cup on the bedside table. Resident #18 further stated the staff give her the Tylenol at night and sit them on her nightstand for her to take when she needs them. Interview with Licensed Practical Nurse (LPN) #87 on 07/25/22 at 11:05 A.M. confirmed the medication on Resident #18's bedside table was Tylenol but was not sure how long they were there. LPN #87 also stated to Resident #18 that the Director of Nursing (DON) wanted to see the pills in the yellow bag. Resident #18 refused to give the bag to LPN #87 and the yellow bag remained in the open top nightstand drawer. Interview and observation on 07/26/22 at 8:45 A.M. with Resident #18 revealed the yellow bag containing the pomalidomide sodium remained in the same spot which was on top of the open nightstand drawer. The two Tylenol tablets were no longer on the bedside table. Resident #18 stated she was given a lock box by the previous DON a long time ago and pointed to the top of her miniature refrigerator. Resident #18 stated she doesn't use the lock box because she can't open it herself and she could not reach it anyway. An interview with the Administrator on 07/27/22 at 5:30 P.M. confirmed the medication in Resident #18's room should have been securely stored. Review of the document titled Bristol [NAME] Squibb Prescribing Information, dated November 2020, revealed for pomalidomide sodium, the drug is to be kept out of reach of children and the capsule should be handled with as little exposure as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Review of the facility's policy titled Medication Storage, dated 07/23/19, revealed all medications and biologicals are to be stored safely, securely, and properly following the manufacturer's instructions. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 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 366472 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capri Gardens 6975 Graphics Way Lewis Center, OH 43035 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. Based on observation, record review, staff interview, and facility policy review, the facility failed to appropriately store, date, and maintain food safety in the kitchen. This affected 74 of 76 residents who receive food from the kitchen (Residents #3 and #34 do not receive food from the kitchen). The facility census was 76. Findings include: Observations on 07/25/22 from 7:35 A.M. to 8:00 A.M. of the kitchen revealed a plastic bag of chicken strips in the walk-in refrigerator that was not dated to when it was opened or when the chicken strips should be used by. Also in the walk in refrigerator, there was an opened bag of lettuce/salad with the perceived date of 06/25/22. The date on the lettuce was fading and very difficult to read. Also, there were brown pieces of lettuce, visible on the bottom of the bag. Then, in the walk-in freezer, the following items were opened without a used by or opened date on them: plastic bag of hash browns, plastic bag of pancakes, plastic bag of waffles, a package of diced ham, and a plastic bag of sausage links. Interview with Dietitian #3 and Dietary Manager #4 on 07/25/22 at 7:50 A.M. and 8:00 A.M. confirmed the bag of chicken strips and all the breakfast items in the basket were opened, did not have opened dates, and should have either had an opened date or a date to use by and confirmed the bag of lettuce should have been thrown out. Review of the facility's list of residents' diets revealed Resident #3 and #34 did not receive food from the kitchen. Review of facility's policy titled Food Storage-Labeling and Dating, dated July 2018, revealed all food must have a date that includes month, date, year on the package indicating the date in which it entered the facility. All items removed from the original packaging must be dated. Items must be dated after opening with an open date and a use by date. The use by date will be seven days (today plus six), unless the original manufacturer expiration date is before the seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366472 If continuation sheet Page 8 of 8