Health inspection·March 12, 2024

F 0689 plan for this to be assessed at least twice per week for four weeks, and then monthly thereafter to ensure they are being followed. This was completed by Program Director #121. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] and [DATE], Program Director #121 assessed all residents who utilized a motorized wheelchair in the facility (Residents #17, #20, and #48) and found no issues with their ability to safely use the wheelchairs. • On [DATE], all nurses were educated by the Executive Director and DHS, about the following policies: Change of Condition policy, Notification of Change policy, Guidelines for Therapy Referral, Physician Provider Notification, Responsible Party Notification, Stop and Watch Early Warning Tool, SBAR communication tool, and Falls Management policy. • On [DATE], the facility implemented the practice of filling out community activity forms with the following information: Residents attending the activity, staff attending the activity, indicating if a resident was in a wheelchair, resident Brief Interview for Mental Status (BIMS) score, location/address of the activity, and name of contact at the activity to confirm if the location was wheelchair accessible. Also, the facility would also send a State Tested Nursing Assistant (STNA) on each outing as well. • On [DATE], all life enrichment (activities) staff were educated by Regional Life Enrichment Staff #120 regarding the following policies: Resident BIMS scores, resident care plans and resident profiles (what they mean and where they can be found in the medical records), and the newly implemented community activity forms. • On [DATE], all therapy staff were educated by Therapy Director #121 on the following policies: screening/observation process of new/existing residents, and Resident First Profile. • On [DATE], the Executive Director reviewed the following policies with no changes needed: fall management policy and resident outings and trips policy. • On [DATE], the facility reviewed the medical records for Resident #17, #20, and #48 to ensure their fall risk assessments, BIMS assessment, therapy evaluations (and recommendations if any), resident profile, and care plans were complete and accurate. No issues were found. • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 2 of 6 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 - Immediate jeopardy to resident health or safety On [DATE], Therapy Staff #300, Activity Associate #105, Activity Associate #102, STNA #106, STNA #107, and Registered Nurse (RN) #108 were interviewed. They confirmed they had received appropriate educations and trainings consistent with the facility's plan of correction. The facility staff interviewed were knowledgeable regarding the education that was provided to them. Findings include: Residents Affected - Few Review of the closed medical record for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, morbid obesity, unspecified convulsions, disorientation, need for assistance with personal care, other lack of coordination, cognitive communication deficit, unsteadiness on feet, dependence on wheelchair, and muscle weakness. Review of Resident #51's plan of care, initiated on [DATE] revealed Resident #51 had significant severe cognitive deficits with further deterioration anticipated due to the intrinsic nature of the disease process. Interventions included to encourage Resident #51 to make simple decisions with limited choices daily, observe cognitive functioning with all hands-on care and contact, and refer significant declines/changes to the physician as needed. A second plan of care, initiated [DATE] revealed Resident #51 had impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness. The long-term goal was for Resident #51 to remain safe and not injure herself, secondary to impaired decision making. Interventions included to determine if decisions made by the resident endanger the resident or others, intervene if necessary; in new situations, provide support and reassure; pay attention to basic needs and provide ADL care as required, provide cues and supervision for decision making, and re-direct Resident #51 when agitated behaviors are present or potential for injury is evident. Additionally, a plan of care initiated [DATE] revealed Resident #51 required staff assistance to complete activities of daily living (ADL) tasks completely and safely related to dementia. Interventions included encourage Resident #51 to do as much as safely possible for self, observe for deterioration in ADL abilities and report if occurs, and therapy evaluation and treat as needed and ordered. Review of the Minimum Data Set 3.0 (MDS) assessment, dated [DATE], revealed Resident #51 had severe cognitive impairment. The assessment revealed Resident #51 was dependent on staff for assistance with transfers, personal hygiene, and bathing/showering. Review of Resident #51's most recent Fall Risk Assessment, dated [DATE], revealed Resident #51 was at moderate risk for falls. Review of Resident #51's progress notes, dated [DATE], revealed the facility documented, Resident noted with fall while on outing. EMS assessed resident. Resident transported to (local hospital) from outing. Daughter and provider updated. There were no other documented progress notes regarding the fall/incident that happened during the community outing on [DATE]. Review of the Emergency Medical Services Patient Care Record, dated [DATE], revealed EMS arrived at the community restaurant on [DATE] at 12:20 P.M. The report indicated Resident #51 was the individual involved and she fell down stairs and steps. Cardiopulmonary Resuscitation (CPR) was started immediately. EMS documented that there was injury and trauma to her airway and her tongue was swollen, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 3 of 6 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 - Immediate jeopardy to resident health or safety Residents Affected - Few which required them to use video to place the breathing tube, which was successful. An intravenous line was placed, and Resident #51 received three, one milligram (mg) doses of epinephrine by the time she reached the hospital. Resident #51 was unresponsive to care and services during the whole time she was in the care of EMS. Injuries noted on the report included open or depressed skull fracture, two or more proximal long bone fractures, and bruising to her lower two abdomen quadrants. Review of the EMS Patient Care Report, dated [DATE], revealed the narrative of the EMS run included the following: EMS was dispatched to a community restaurant for a person (Resident #51) who had fell down the stairs and was not breathing. Local fire department was dispatched also for the manpower. When they arrived at the scene, unknown females met them outside the restaurant and stated, she is dead, she caved her head in, there is nothing you can do. EMS went to where Resident #51 was located and found Resident #51 laying in the prone position at the bottom of the staircase. She was pulseless and apneic (involuntary or temporary pause in breathing). EMS repositioned Resident #51 on the floor and began manual compressions. A cardiac monitor and ventilator were placed to continue life sustaining measures. An initial heart rhythm of asystole (the cessation of electrical and mechanical activity of the heart) was noted. EMS took Resident #51 to the ambulance and transported her to the emergency room. Resuscitation efforts continued the entire time she was in the ambulance as well. Review of Resident #51's hospital records, dated [DATE], revealed on [DATE], she arrived at the emergency room with EMS performing CPR. The EMS personnel stated Resident #51 had a fall in her motorized wheelchair of approximately 25 stairs at the community restaurant, and when they arrived, she was in asystole (at the bottom of the stairs). EMS intubated her, placed an intraosseous IV and gave her epinephrine. Resident #51 had pulseless electrical activity (PEA) without the return of spontaneous circulation. No other information was available at that time. Physical exam of Resident #51 included a large laceration to the left forehead with large hematomas noted, an open fracture of the mid left tibia and fibula, and laceration to the mid right leg. At a later time, the hospital received more information that Resident #51 was seen on the camera at the restaurant and appeared to go headfirst over the staircase in her motorized wheelchair. Interview with Restaurant Owner #207 on [DATE] at 2:35 P.M. revealed she was in the building at the time of the incident with Resident #51. She stated the residents were in the gift shop by themselves. One of the facility staff had taken a couple residents to the dining room, which was out of sight of the gift shop. The other two male facility staff were outside assisting residents into the building, with one of the facility staff opening the front doors to the restaurant/gift shop. One of the male facility staff ran inside the gift shop and ran down the stairs to see if he could help as soon as he heard Resident #51 fell down the stairs. Restaurant Owner #207 indicated EMS was called to assist with the situation. Interview with Activities Associate #102 on [DATE] at 3:15 P.M. revealed Resident #51 was the first resident/wheelchair off the bus. He stated he assisted Resident #51 off the wheelchair lift and walked with her (and others) into the restaurant. He opened both sets of entry doors to allow Resident #51 to maneuver herself into the gift shop of the restaurant. He stated approximately four to six residents were in the restaurant at this time, but he did not know where they all were. He confirmed another female staff (Activities Associate #101) was already in the restaurant with a few residents. He stated when Resident #51 went through the second entry door into the restaurant, he asked her to wait. She continued in her motorized wheelchair without stopping/waiting. Activities Associate #102 then said are you ok to Resident #51 and stated she nodded her head and indicated that she was, so he let her continue while he kept holding the doors. He revealed he did not see Resident #51 fall. When he heard that Resident #51 fell, he stated he was near the doors, so he ran to the stairs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 4 of 6 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 - Immediate jeopardy to resident health or safety Residents Affected - Few down them to see if he could help. One of the community members at the bottom of the stairs told him that Resident #51 did not have a pulse. He revealed a community member told him that EMS was called. During the interview, Activities Associate #102 revealed he had been employed with the facility for approximately three and a half weeks. He revealed they did not really discuss a plan as to who would take which residents into the facility and where each staff person would be when they got into the restaurant, but they had all gone on activities together before and they kept with the same plan. He was not able to explain/express what the same plan was. Interview with Transportation Associate #103 on [DATE] at 3:35 P.M. revealed he was the bus driver for six of the residents who went to the restaurant on [DATE]. He revealed he was outside of the restaurant when Resident #51 fell. He indicated he does not know where the other two staff were at the time of Resident #51's fall because he was assisting residents off of the bus. Interview with Activity Associate #101 on [DATE] at 3:50 P.M. revealed upon arriving to the restaurant, she entered with three residents. She revealed she went to the dining area of the restaurant with three other residents to pick the table and chairs for the entire group. While she was in the dining area, she was told by a restaurant staff person that one of their residents fell down the stairs. When she got to the gift shop area of the restaurant, Activities Associate #102 was at the bottom of the stairs checking on Resident #51. She revealed she called Life Enrichment Director (LED) #104 immediately after Resident #51's fall to report the incident. She stated when they got off the bus, prior to the fall, she told the two other staff that she would take a couple residents into the restaurant to get the table/chairs set up for all nine residents. She revealed she was in the dining area and did not see Resident #51 fall. Interview with Law Enforcement #206 on [DATE] at 9:11 A.M. revealed he watched the restaurant video of Resident #51 falling down the stairs. He stated it appeared Resident #51 turned near the corner of the stairs and fell straight down the stairs. Review of restaurant security camera video footage on [DATE] at 12:35 P.M. revealed the video was one minute and two seconds in length. The date on the video was [DATE] at approximately 12:23 P.M. and the title of the video was gift shop. Immediately as the video started, Resident #51 could be seen in her motorized wheelchair between the half wall of the stairway to the basement, and the exterior wall of the giftshop/restaurant; not very far from exterior door. Approximately 13 seconds after the video started, Resident #51 could be seen independently maneuvering her motorized wheelchair from the exterior door, to the back/middle section of the gift shop, where the top of the staircase was located. Approximately 19 seconds after the video started, Resident #51 could be seen facing the top of the staircase in her motorized wheelchair. Resident #51 then continued to independently maneuver her motorized wheelchair towards the stairs and proceeded to fall down the stairs with her motorized wheelchair. Resident #51 was then seen rolling down the stairs in her motorized wheelchair. At no point did it appear that Resident #51 stopped her wheelchair prior to falling down the staircase. Approximately four seconds after Resident #51 initially fell, video showed a person (identified to be Activities Associate #102) run from the exterior door to the top of the staircase. Approximately 10 seconds after the initial fall, Activities Associate #102 could be seen going down the stairs. For the other 32 seconds of the video, no other facility staff went into the gift shop area. At the time Resident #51 fell, there were no facility staff observed around Resident #51 to provide supervision/assistance or to ensure the environment was safe for Resident #51 while in the gift shop area. Interview with Coroner #205 on [DATE] at 12:58 P.M. revealed they would be completing an autopsy due to the nature of Resident #51's death. He stated based on the medical evaluation he had completed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 5 of 6 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 366474 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Violet Springs Health Campus 603 Diley Road Pickerington, OH 43147 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 - Immediate jeopardy to resident health or safety Residents Affected - Few thus far, Resident #51 had the following injuries: multi-bilateral rib fractures which would have severely hindered Resident #51's breathing, complete dissection of the T11 and T12 thoracic spine, and C1 and C2 fracture with spinal cord traction. He stated he had not made a formal cause of death, but the most likely reason was multiple blunt force trauma accident. Interview with the Administrator on [DATE] at 8:05 A.M. confirmed the sequence of events that Activities Associate #102 reported, due to the information being reported to her in the same manner when she arrived at the restaurant. Activities Associate #102 was opening the door for Resident #51 and asked her to wait; however, she did not wait so Activities Associate #102 asked Resident #51 if she was ok and Resident #51 indicated she was. The Administrator confirmed Activities Associate #101 was in the dining area (The dining area was away from the gift shop area which was where the stairs were located). The Administrator confirmed she saw the restaurant video and there appeared to be no delay or hesitation with Resident #51 from turning right and around the corner of the gift shop and when she fell down the stairs. She stated the facility set staffing levels for community outings based on the level of the needs of the residents and they do not have a set number of staff that go on outings. Interview with Program Director #121 on [DATE] at 8:20 A.M. revealed Resident #51 had continued therapy with her motorized wheelchair for repetition and muscle memory. She revealed Resident #51 could not retain information about her motorized wheelchair or the ability to use it, other than what she had already retained. Resident #51 had maximized the amount of information about her wheelchair and how to use it, which was why they were performing therapy services related to maneuvering the wheelchair and turning it off/on three days per week as repetition. Review of the facility policy titled Resident Outings and Trips policy, dated [DATE], revealed the site chosen for the outing would be checked and reviewed for safety and accessibility. Notification of all proposed outings would be communicated to the Executive Director and Director of Health Services to support staffing ratios during outings. Campus staff to resident ratio would vary according to the type of outing, number of residents/patients, and the mental and physical functioning of the residents/patients. This deficiency represents non-compliance investigated under Complaint Number OH00151548. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366474 If continuation sheet Page 6 of 6