Health inspection·July 6, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #27 reveled Resident #27 was most recently admitted on [DATE] with diagnoses that included intertrochanteric fracture of right femur, chronic infected abdominal mesh, atherosclerotic heart disease, atrial fibrillation, venous insufficiency, emphysema, chronic obstructive pulmonary disease, post-traumatic stress disorder, type 2 diabetes mellitus, depression, legal blindness, history of chest pain, hypertension, chronic pain, falls, insomnia, and muscle spasms. Residents Affected - Few Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #27 was cognitively intact with no symptoms of depression. Resident #27 required extensive assistance from two people for bed mobility, transfers, toileting, and personal hygiene. Resident #27 required supervision for eating and had episodes of coughing and choking during meals so Resident#27 was on a mechanical soft diet. Record Review revealed on 05/05/23, the resident weighed 127.4 pounds. On 06/17/23 the resident weighed 114.2 pounds which is a 10.36% weight loss. There was no documentation that the physician or family were notified of the significant weight loss. Review of speech therapy notes dated 06/29/23 and 06/30/23 revealed Resident #27 progressed from a mechanical soft diet to regular texture diet with difficult to chew meats ground. Resident #27 was eating without difficulty. 07/05/23 11:50 AM review of orders with administrator and found the diet order was changed on 06/29/23 from controlled/consistent carbohydrate diet (CCHO) mechanical soft to CCHO regular textures with mechanical soft textures for special items. On 07/04/23 the order was modified to read CCHO regular textures with chopped meat and thin liquids. The administrator verified there was no documentation present for notification of significant weight loss in the medical record for Resident #27. 07/05/23 12:23 PM - Interview with dietician #81 revealed she initially visited Resident #27 to determine likes and dislikes and worked with Resident #27 to select alternative foods he would eat. Resident #27 is one of the residents she is to evaluate today. Dietician #81 is normally at the facility once a week so significant weight loss notification should be done by nursing staff at the time the weights are done. The resident has continued to progress with eating more and taking supplements with continued weight loss. Care plan in place to continue to monitor and improve weight gain. Review of policy Notification of Changed dated 12/31/22 revealed a significant change in a resident's physical, mental or psychosocial condition should be reported to the physician and the resident's representative in a timely manner. Review of policy Guidelines for Weight Tracking dated 12/31/22 revealed the physician, resident representative,and dietician shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days (unless planned weight loss). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 2 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 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** Based on observation, medical record, review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, policy review, and interviews, the facility failed to ensure residents unable to carry out activities of daily living including bathing received the necessary services. This affected five residents (Residents #87, #187, #26, #3, and #23) of six residents reviewed for bathing. The facility census was 36 Residents Affected - Some Findings include: Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 37 residents. The ADL information revealed the facility identified 21 residents who required the assist of one or two staff for bathing and 16 residents that were dependent for bathing. 1. Review of medical record revealed Resident #87 was admitted on [DATE] and discharged on 06/03/23 with diagnoses that included but not limited to non-traumatic spinal cord dysfunction, atrial fibrillation, and depression. Review of the bathing documentation from 05/13/23 to 06/04/23 revealed Resident #87 was bathed once on 06/01/23. Review of the 5-day Minimum Data Set (MDS) 3.0 dated 05/20/23 revealed Resident #87 was cognitively intact. Resident #87 required extensive assist of one for bed mobility and toilet use and extensive assistance of two for transfers. The MDS revealed bathing activity did not occur during the assessment period. Review of the plan of care dated 05/30/23 revealed Resident #87 required staff assistance to complete ADL tasks completely and safely. Interventions included to offer nail care on shower days and as needed. Interview on 07/06/23 at 2:15 P.M. Executive Director (ED) verified there was no documentation of Resident #87 being bathed/showered from 05/13/23 to 05/31/23. Review of the policy Guidelines for Bathing Preference dated 12/31/22 revealed residents are to be advised of the bathing preference policy and the resident shall determine their preferences on admission for the day of the week, time of day, and type of bathing preferred. The policy also revealed bathing was to occur at least twice a week unless the resident preferred otherwise. Review of the policy Nursing ADL Documentation Guidelines dated 12/31/22 revealed all care givers are expected to document the completion of ADL services at the time of completion or as soon as reasonably possible after completion. 3. Observation on 07/03/23 at 8:49 A.M. revealed Resident #26's hair appeared greasy and unkempt. Interview on 07/03/23 at 8:49 A.M. with Resident #26 revealed she was supposed to get bed baths two times a week but was 'lucky' to get them one time a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 3 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 - Some Review of the medical record for Resident #26 revealed an admission date of 12/20/22 with diagnoses including heart failure, paraplegia, pressure ulcer of sacral region, type two diabetes mellitus, cognitive communication deficit, and moderate protein-calorie malnutrition. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and was totally dependent on staff for bathing. Review of the plan of care dated 05/22/23 revealed Resident #26 required staff assistance to complete activity of daily living tasks (ADL) completely and safely. She required one to two person assistance and a hoyer lift. Interventions included allowing the resident sufficient time to complete tasks, encouraging resident to do as much as possible, observing for deterioration in ADL abilities, and providing nail care on shower days. Review of the shower schedule revealed Resident #26 was to receive baths or showers on Tuesday's and Friday's during the day. Review of the electronic medical record from 06/10/23 to 07/03/23 revealed Resident #26 had received a partial bed bath on 06/11/23 and 06/15/23 and a complete bed bath on 06/20/23, and 06/27/23. Based on the shower schedule she should have received six showers or bed baths in that time frame. Review of the progress notes from 06/10/23 to 07/03/23 revealed no documentation related to shower or bath refusals. Interview on 07/03/23 at 4:32 P.M. with the Administrator verified the shower documentation. The Administrator revealed Resident #26 refused showers at times, however, she verified it was not in the medical record she refused showers and should have been. 4. Interview on 07/03/23 at 11:06 A.M. with Resident #3's daughter revealed the facility had insufficient staff to do showers for her mother. Resident #3's daughter reported when her mother went too long without a shower, she would do it herself just to make sure she was clean. She reported this was not something she wanted to do but something she felt she had to do. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. She was totally dependent for bathing and eating. Review of the plan of care dated 04/10/20 revealed Resident #3 required staff assistance to complete ADL tasks completely and safely related to her diagnoses, decreased strength and mobility, and impaired cognition. Her daughter gave the resident showers at times. Interventions included hoyer lift for all transfers, allowing sufficient time to complete task, encourage resident to do as much as possible for herself, providing adequate rest, and observing for deterioration in ADL abilities. Review of the shower schedule revealed Resident #3 should have received a shower on Wednesdays and Saturdays during the day. Review of the electronic medical record for Resident #3 from 06/03/23 to 07/02/23 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 4 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 resident received a shower or bed bath on 06/08/23, 06/15/23, 06/17/23, 06/18/23, 06/20/23, and 06/24/23. Level of Harm - Minimal harm or potential for actual harm Review of the shower sheets from 06/03/23 to 07/02/23 revealed the resident received a shower or bed bath on 06/04/23 from her daughter. Residents Affected - Some Review of the shower schedule and shower documentation revealed Resident #3 did not receive a bed bath or shower per her schedule on 06/03/23, 06/07/23, 06/10/23, 06/14/23, 06/21/23, 06/28/23, or 07/01/23. Interview on 07/03/23 at 4:32 P.M. with the Administrator revealed Resident #3's family provides a lot of care and showers for her as listed in the care plan. She verified there was no electronic documentation to indicate a family or non-facility staff provided a shower. 5. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She was totally dependent on two staff for bathing. Review of the plan of care dated 08/29/22 revealed Resident #23 required staff assistance to complete ADL tasks completely and safely. She required one-to-two-person assistance. Interventions included allowing the resident sufficient time to complete tasks, encouraging her to do as much as safely possible for self, observe for deterioration in activity of daily living abilities, provide rest periods, and providing nail care on shower days. Review of the shower schedule revealed Resident #23 was not on it. Review of the Resident #23's shower documentation revealed family or non-facility staff provided a bed bath on 06/06/23, 06/13/23, 06/15/23, 06/19/23, and 06/28/23. Facility staff provided a bed bath on 06/18/23, 06/20/23, and 06/27/23. The documentation indicated Resident #3 received a bed bath on 06/06/23 and not again until 06/13/23 and received a bed bath on 06/20/23 and not again until 06/27/23. Interview on 07/03/23 at 4:32 P.M. with the Administrator verified the shower documentation as provided. She reported between hospice and the facility she felt Resident #23 was getting sufficient showers. Review of the policy titled Guidelines for Bathing Preference dated 12/31/22 revealed bathing was to occur at least twice a week unless resident preferred otherwise. This deficiency represents non-compliance investigated under Complaint Number OH00143884 and OH00143745. 2. Review of the medical record for Resident #187 revealed an admission date of 06/28/23 with diagnoses including displaced intertrochanteric fracture of left femur, hypertensive chronic kidney disease stage 3, osteoporosis, overactive bladder, and hyperlipidemia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 5 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 - Some Review of the admission MDS 3.0 dated 07/02/23 revealed Resident #187 was cognitively intact with no symptoms of depression. Bed mobility and toileting required extensive assistance of one person. 07/03/23 at 10:01 A.M. Interview with Resident #187 revealed Resident #187 had not had a bath or shower since admission on [DATE]. Resident #187 voiced understanding getting out of bed was challenging but no one had shared what days to expect to shower, no one even offered assistance to wash or clean up while in bed since her admission. Review of electronic documentation for Resident #187 revealed bathing documentation for 06/28/23, 06/29/23, 07/01/23, and 07/02/23 all stated activity did not occur. 07/03/23 04:36 P.M. interview with administrator verified Resident #187 has no documentation of a shower or bed bath since admission on [DATE]. Review of the policy Guidelines for Bathing Preference dated 12/31/22 revealed residents are to be advised of the bathing preference policy and the resident shall determine their preferences on admission for the day of the week, time of day, and type of bathing preferred. Review of the policy Nursing ADL Documentation Guidelines dated 12/31/22 revealed all care givers are expected to document the completion of ADL services at the time of completion or as soon as reasonably possible after completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 6 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure activities were provided for one resident (#3). This affected one resident (#3) of two residents reviewed for activities. The facility census was 36. Residents Affected - Few Findings include: Observation on 07/03/23 at 9:20 A.M. and 11:27 A.M. and on 07/05/23 at 9:05 A.M. and 3:41 P.M. revealed Resident #3's television was on but muted. Interview on 07/03/23 at 10:58 A.M. with Resident #3's daughter revealed she was concerned about her mother's activities. She reported they did not do activities with Resident #3, and nobody visited her. She reported she had been told Resident #3 gets 30 minutes of activities a week, but she had not seen it. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. Review of the plan of care dated 06/19/20 revealed Resident #3 had senile degeneration of the brain with depression, anxiety disorder, and dependence for mobility. It was important to her that she had the opportunity to engage in activities and opportunities that were meaningful to her. She enjoyed spending time napping and spending time with family. She additionally enjoyed happy hour, relaxing music, animals, and other social events. She had a need for one-on-one activities due to her dementia diagnoses and dependence for engagement. Interventions included inviting to programs of interest, providing weekly one on one activities to supplement her engagement, playing music while in room, offer to participate in happy hour, and socialize with family. Review of the life enrichment assessment dated [DATE] revealed reading was not important to her, keeping up with the news, getting fresh air, and doing things in groups was somewhat important to her, and listening to music, participating in religious practices, and seeing pets was very important. It indicated she liked participating in happy hour, spending time with family, listening to music, and themed dinners were her favorite activities. She was to engage in weekly one on one, family and group programs of interest. Review of the activity's documentation from 06/07/23 to 07/05/23 revealed Resident #3 had four family visits on 06/18/23, 06/20/23, 06/22/23, and 06/23/23, and another visit on 06/30/23. Interview on 07/05/23 at 3:32 P.M. with Life Enrichment Director (LED) #30 revealed Resident #3 was mostly one-on-one visits because of her cognition. She reported during group activities Resident #3 fell asleep in her chair. Resident #3 liked soft music, conversation, and being read to. LED #30 verified Resident #3's documentation indicated only on facility visit from 06/07/23 to 07/05/23. Review of the policy Individual Program Planning dated 06/02/16, revealed individual programming (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 7 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0679 Level of Harm - Minimal harm or potential for actual harm ensured all residents who are unable to participate in group programs have consistent, goal oriented, and individualized recreation opportunities. Each residents individual program will include interventions which meet the resident's assessed needs. Based on the assessed needs the life enrichment director will establish a schedule of visitation for each resident that provides consistency of delivery of life enrichment services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 8 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 observation, interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place for one resident (#23) who was at risk for falling. This affected one resident (#23) of four reviewed for accidents. The facility census was 36. Findings include: Observation on 07/03/23 at 8:33 A.M., 9:32 A.M., 12:08 P.M., and 12:30 P.M. revealed Resident #23 in bed. No fall mats were observed. Interview on 07/03/23 with Certified Resident Care Associate (CRCA) #72 verified no fall mats were in place. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. Review of the plan of care dated 08/29/22 revealed Resident #23 was at risk for falling related to impaired cognition, poor safety awareness, incontinence, weakness, and medication side effects. Interventions included floor mat at bedside, low bed, providing non-skid footwear, keeping call light in reach, and keeping personal items in reach. Review of the physician order dated 11/18/22 revealed fall mats were to be next to Resident #23's bed while she was in it for safety. Review of the policy Falls Management Program Guidelines dated 03/16/22 revealed any orders received from the physician should be noted and carried out. This deficiency represents non-compliance investigated under Complaint Number OH00143745. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 9 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure supplements were provided as ordered and weights were obtained as ordered for Residents #3 and Resident #23. This affected two residents (#3 and #23) of four reviewed for nutrition. The facility census was 36. Residents Affected - Few Findings include: 1. Observation on 07/03/23 at 12:30 P.M. revealed Resident #23 did not have a magic cup on her lunch tray. This was verified by Certified Resident Care Associate (CRCA) #72 at that time who reported she would get the resident one after she was done eating. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She required the supervision of one person for eating. She had no weight indicated and was on a mechanically altered diet. Review of the plan of care dated 10/27/22 revealed Resident #23 was on hospice with the potential for unavoidable weight loss and nutritional decline. She had a risk for sub-optimal oral intakes related to dementia, she had dysphagia warranting modified texture diet and thickened liquids for management. She was receiving nutritional supplements. Interventions included allowing the resident to eat and drink as able, offering alternate and substitute items if needed, and weighing monthly as ordered. Review of the physician order dated 08/23/22 revealed Resident #23 was to get Magic Cup twice a day. Review of the Medication Administration Record (MAR) for 06/04/23 to 07/04/23 revealed Magic Cup consumption was marked as 'none' on 06/15/23, 06/22/23, 06/28/23, and 06/29/23 and on 06/17/23 for afternoon administration. Notes on 06/15/23 indicated the resident was no longer getting magic cup routinely on tray, on 06/22/23 it was indicated it was on hold and not being given any more; on 06/28/23 it was reported she was no longer getting it, and on 06/29/23 it was indicated she was no longer getting it. Review of Resident #23's weights revealed on 12/21/22 she weighed 122.6 pounds, on 01/19/23 she weighed 125 pounds, on 02/19/23 she weighed 126.6 pounds, on 03/18/23 she weighed 128.9 pounds, on 05/22/23 she weighed 124.3 pounds, and on 06/17/23 she weighed 124.8 pounds. Interview on 07/05/23 at 12:00 P.M. with Area Director of Food Services #56 verified magic cup should have been on Resident #23's lunch tray. Interview on 07/05/23 at 12:20 P.M. with Dietitian #81 verified Resident #23 was missing an April weight. She reported she was unsure what the issue was. She additionally reviewed the MAR and verified the order was still in place and Resident #23 should have been receiving the magic cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 10 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy titled 'Nutritional Supplements' dated 11/11/22, revealed Staff were to document the amount of nutritional supplements consumed as ordered. Review of the policy titled 'Guidelines for Weight Tracking' dated 12/31/22, revealed unless otherwise indicated or ordered by the physician residents were to have their weight taken and recorded monthly. Residents who have weight that seems out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative, and dietitian shall be notified of weight variances of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. 2. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. She was totally dependent for bathing and eating. She had lost weight not while on a physician-prescribed weight loss plan. Review of the plan of care dated 10/20/21 revealed Resident #3 was malnourished or at risk for malnutrition related to diagnoses, inadequate intake, or metabolic demands. Resident #3's 05/19/23 weight was noted to be a significant weight loss over 180 days. Additionally, she was noted to have a modified textured diet. Interventions included assisting with meals as needed, dietitian evaluation as indicated, obtaining weights as ordered, offering alternate food and beverages as needed, and providing diet, supplements, and medications as ordered. Review of Resident #3's weight history revealed she weighed 122.8 pounds on 11/09/22, 123.1 pounds on 12/09/22, 121.2 pounds on 01/19/23, 121 pounds on 02/18/23, 119.3 pounds on 03/03/23, 120.4 pounds on 03/09/23, and 109.6 pounds on 05/09/23. Her 05/09/23 weight was a 10.7% weight loss over 180 days. She had no further weights recorded. A weight was obtained on 07/05/23 following surveyor's request and was 119.7 pounds. Review of the weight note dated 05/19/23 revealed Resident #3's weight of 109.6 was a significant weight change and was below her typical weight change. A reweigh was recommended to confirm accuracy. Resident #3 had varied meal intakes and poor oral nutrition supplement acceptance. Her intakes varied from 26-100%. Her supplements included Ensure Plus twice a day with poor acceptance and magic cup daily. An additional recommendation was to change ensure to Med Pass 2.0 120 milliliters twice a day to encourage acceptance. Review of the 06/02/23 quarterly nutrition note revealed Resident #3's weight of 109.6 pounds was still used. No new interventions were noted. Review of the physician order dated 07/05/23 revealed Resident #3 was to receive a magic cup once a day. Review of the medication Administration Record (MAR) for 06/04/23 to 07/04/23 revealed intake documentation was listed as 'none' on 06/05/23, 06/06/23, 06/07/23, 06/09/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/16/23, 06/18/23, 06/19/23, 06/20/23, 06/27/23, 06/28/23, 06/29/23, and 07/01/23. There was no amount consumed on 06/17/23 and 06/22/23. Review of the nurse's notes revealed on 06/14/23 it was indicated Resident #3 was not getting the magic cup routinely anymore, on 06/15/23 Resident #3 did not have a magic cup on tray, on 06/22/23 it was noted she was not receiving it anymore, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 11 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0692 on 06/28/23 it was indicated she was not receiving it anymore. Level of Harm - Minimal harm or potential for actual harm Interview on 07/05/23 at 12:20 P.M. with Dietitian #81 revealed she was aware of Resident #3's missing weights and reported she notified the nursing staff when she was missing weights as well. She reviewed the MAR and verified the Magic Cup order remained and the resident should have received it. Residents Affected - Few Review of the policy titled 'Nutritional Supplements' dated 11/11/22, revealed Staff were to document the amount of nutritional supplements consumed as ordered. Review of the policy titled 'Guidelines for Weight Tracking' dated 12/31/22, revealed unless otherwise indicated or ordered by the physician residents were to have their weight taken and recorded monthly. Residents who have weight that seems out of normal range shall be re-weighed to determine the accuracy of the original weight. The physician, resident representative, and dietitian shall be notified of weight variances of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 12 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record, review, staffing schedule review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, review of the facility assessment, and interviews, the facility failed to ensure there was adequate staffing to provide bathing for residents. This affected five residents (Residents #3, #23, #26, #87, and #187) of six residents reviewed for bathing with the potential to affect all 36 residents. The facility census was 36. Findings include: 1. On 07/03/23 at 7:30 A.M. three surveyors entered the facility to conduct an annual and complaint investigation. Observation revealed there were two licensed nurses, one licensed nurse in training, and three State Tested Nurse Aides (STNA's) on duty to proved care for 36 residents currently residing in the facility. Review of the facility completed Centers for Medicare and Medicaid (CMS) Census and Condition form 672 revealed the facility provided Activities of Daily Living (ADL) information for 37 residents. The ADL information revealed the facility had one resident that was independent with dressing and 21 residents that were independent for eating. The facility identified 21 residents who required the assist of one or two staff for bathing and 16 residents who were totally dependent on staff. The facility identified 33 residents who required the assist of one or two staff for dressing and three residents that were totally dependent on staff. The facility identified 26 residents who required the assist of one or two staff for transfers and 11 who were totally dependent on staff. The facility identified 32 residents who required the assist of one or two staff for toileting and five residents who were totally dependent on staff. The facility identified 15 residents who required the assist of one to two staff for eating and one resident who was totally dependent on staff. 2. The following resident concerns were lodged during the investigation related to facility staffing. a. Interview on 07/03/23 at 8:49 A.M. Resident #26 revealed the facility was short staffed. New employees did not stay due to the work load and there not being enough staff. Resident #26 stated it could take up to 30 minutes for call lights to be answered. b. Interview on 07/03/23 at 9:05 A.M. Resident #8 revealed they were scheduled to receive showers on Mondays and Thursdays but did not always receive showers on the scheduled days. Resident #8 stated it was getting better. c. Interview on 07/03/23 at 9:42 A.M. Resident #187 revealed the previous night it took three hours to get a second person to get pulled up in bed. Resident #187 stated at night it took an average of 45 minutes to an hour to get staff to assist Resident #187 off the bedside commode. d. Interview on 07/03/23 at 10:23 A.M. Resident #27 revealed it could take two hours to get a staff member to respond to call lights and it was worse at night. e. Interview on 07/03/23 at 11:17 A.M. family of Resident #3 revealed they visited or paid someone every morning and evening to feed Resident #3 because the facility did not have enough staff to feed Resident #3. Family of Resident #3 stated Resident #3 was not bathed unless the family showered Resident #3. The family member stated they were told that due to census the staffing consisted of two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 13 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many nurses and two STNA's. Family of Resident #3 stated there were a lot of residents that needed assistance on the 400 hall where Resident #3 resided and two STNA's were needed for just that hall. f. Interview on 07/03/23 at 1:23 P.M. Resident #17 revealed it took a long time for staff to answer call lights. Resident #17 also stated it was difficult to get two staff members at the same time to transfer Resident #17 in and out of bed. 3. The following staff concerns were lodged during the investigation related to facility staffing. a. Interview on 07/06/23 at 7:44 A.M. Licensed Practical Nurse (LPN) #69 revealed at night there were usually two nurses and two to three STNA's. The two nurses also had to cover the assisted living facility and the memory care unit in the attached assisted living facility. LPN #69 verified showers were not always done as scheduled due to staffing. b. Interview on 07/06/23 at 8:32 A.M. Registered Nurse (RN) #70 revealed the facility staffed according to census. The facility had low census of 36 so the staffing was usually two nurses and two STNA's. If new staff were hired, they usually left due to there not being enough staff to provide resident care. RN #70 verified showers were not done due to there not being enough staff to provide the care needed. c. Interview on 07/06/23 at 11:15 A.M. Certified Resident Care Associate (CRCA) #72 revealed someone had called off on 07/06/23. CRCA #72 stated there was not always sufficient staff to provide the care the residents needed. CRCA #72 verified there were times showers were not done due to staffing. 4. During the staffing investigation concerns were identified that residents were not provided routine showers/baths. a. Review of medical record revealed Resident #87 was admitted on [DATE] and discharged on 06/03/23 with diagnoses that included but not limited to non-traumatic spinal cord dysfunction, atrial fibrillation, and depression. Review of the bathing documentation from 05/13/23 to 06/04/23 revealed Resident #87 was bathed once on 06/01/23 when Resident #87 received a shower. Review of the 5-day Minimum Data Set (MDS) 3.0 dated 05/20/23 revealed Resident #87 was cognitively intact. Resident #87 required extensive assist of one for bed mobility and toilet use and extensive assistance of two for transfers. The MDS revealed bathing activity did not occur during the assessment period. Review of the plan of care dated 05/30/23 revealed Resident #87 required staff assistance to complete ADL tasks completely and safely. Interventions included to offer nail care on shower days and as needed. Interview on 07/06/23 at 2:15 P.M. Executive Director (ED) verified there was no documentation of Resident #87 being bathed/showered from 05/13/23 to 05/31/23. b. Review of the medical record for Resident #187 revealed an admission date of 06/28/23 with diagnoses including displaced intertrochanteric fracture of left femur, hypertensive chronic kidney disease stage 3, osteoporosis, overactive bladder, and hyperlipidemia. Review of the admission MDS 3.0 dated 07/02/23 revealed Resident #187 was cognitively intact with no symptoms of depression. Bed mobility and toileting required extensive assistance of one person. Interview on 07/03/23 at 10:01 A.M. Resident #187 revealed they had not had a bath or shower since admission on [DATE]. Resident #187 voiced understanding getting out of bed was challenging but no one had shared what days to expect to shower, no one even offered assistance to wash or clean up while in bed since her admission. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 14 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many electronic documentation for Resident #187 revealed bathing documentation for 06/28/23, 06/29/23, 07/01/23, and 07/02/23 all stated activity did not occur. Interview on 07/03/23 at 4:36 P.M. Administrator verified Resident #187 has no documentation of a shower or bed bath since admission on [DATE]. c. Observation on 07/03/23 at 8:49 A.M. revealed Resident #26's hair appeared greasy and unkempt. Interview on 07/03/23 at 8:49 A.M. with Resident #26 revealed she was supposed to get bed baths two times a week but was 'lucky' to get them one time a week. Review of the medical record for Resident #26 revealed an admission date of 12/20/22 with diagnoses including heart failure, paraplegia, pressure ulcer of sacral region, type two diabetes mellitus, cognitive communication deficit, and moderate protein-calorie malnutrition. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and was totally dependent on staff for bathing. Review of the plan of care dated 05/22/23 revealed Resident #26 required staff assistance to complete activity of daily living tasks (ADL) completely and safely. She required one to two person assistance and a hoyer lift. Interventions included allowing the resident sufficient time to complete tasks, encouraging resident to do as much as possible, observing for deterioration in ADL abilities, and providing nail care on shower days. Review of the shower schedule revealed Resident #26 was to receive baths or showers on Tuesday's and Friday's during the day. Review of the electronic medical record from 06/10/23 to 07/03/23 revealed Resident #26 had received a partial bed bath on 06/11/23 and 06/15/23 and a complete bed bath on 06/20/23, and 06/27/23. Based on the shower schedule she should have received six showers or bed baths in that time frame. Review of the progress notes from 06/10/23 to 07/03/23 revealed no documentation related to shower or bath refusals. Interview on 07/03/23 at 4:32 P.M. with the Administrator verified the shower documentation. The Administrator revealed Resident #26 refused showers at times, however, she verified it was not in the medical record she refused showers and should have been. d. Interview on 07/03/23 at 11:06 A.M. with Resident #3's daughter revealed the facility had insufficient staff to do showers for her mother. Resident #3's daughter reported when her mother went too long without a shower, she would do it herself just to make sure she was clean. She reported this was not something she wanted to do but something she felt she had to do. Review of the medical record for Resident #3 revealed an admission date of 04/03/20 with diagnoses including dysphagia, unspecified dementia, depression, type two diabetes, anxiety disorder, and feeding difficulties. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. She was totally dependent for bathing and eating. Review of the plan of care dated 04/10/20 revealed Resident #3 required staff assistance to complete ADL tasks completely and safely related to her diagnoses, decreased strength and mobility, and impaired cognition. Her daughter gave the resident showers at times. Interventions included hoyer lift for all transfers, allowing sufficient time to complete task, encourage resident to do as much as possible for herself, providing adequate rest, and observing for deterioration in ADL abilities. Review of the shower schedule revealed Resident #3 should have received a shower on Wednesdays and Saturdays during the day. Review of the electronic medical record for Resident #3 from 06/03/23 to 07/02/23 revealed the resident received a shower or bed bath on 06/08/23, 06/15/23, 06/17/23, 06/18/23, 06/20/23, and 06/24/23. Review of the shower sheets from 06/03/23 to 07/02/23 revealed the resident received a shower or bed bath on 06/04/23 from her daughter. Review of the shower schedule and shower documentation revealed Resident #3 did not receive a bed bath or shower per her schedule on 06/03/23, 06/07/23, 06/10/23, 06/14/23, 06/21/23, 06/28/23, or 07/01/23. Interview on 07/03/23 at 4:32 P.M. with the Administrator revealed Resident #3's family provides a lot of care and showers for her as listed in the care plan. She verified there was no electronic documentation to indicate a family or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 15 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0725 non-facility staff provided a shower. Level of Harm - Minimal harm or potential for actual harm e. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She was totally dependent on two staff for bathing. Review of the plan of care dated 08/29/22 revealed Resident #23 required staff assistance to complete ADL tasks completely and safely. She required one-to-two-person assistance. Interventions included allowing the resident sufficient time to complete tasks, encouraging her to do as much as safely possible for self, observe for deterioration in activity of daily living abilities, provide rest periods, and providing nail care on shower days. Review of the shower schedule revealed Resident #23 was not on it. Review of the Resident #23's shower documentation revealed family or non-facility staff provided a bed bath on 06/06/23, 06/13/23, 06/15/23, 06/19/23, and 06/28/23. Facility staff provided a bed bath on 06/18/23, 06/20/23, and 06/27/23. The documentation indicated Resident #3 received a bed bath on 06/06/23 and not again until 06/13/23 and received a bed bath on 06/20/23 and not again until 06/27/23. Interview on 07/03/23 at 4:32 P.M. with the Administrator verified the shower documentation as provided. She reported between hospice and the facility she felt Resident #23 was getting sufficient showers. Residents Affected - Many Review of the policy Guidelines for Bathing Preference dated 12/31/22 revealed residents are to be advised of the bathing preference policy and the resident shall determine their preferences on admission for the day of the week, time of day, and type of bathing preferred. The policy also revealed bathing was to occur at least twice a week unless resident preferred otherwise. 5. Review of the Facility assessment dated [DATE] revealed the staffing plan of full-time employees per day was eight nurses and 13 STNA's based on a daily census of 38. Review of the schedules for June and July revealed there were usually three to five nurses and three to five STNA's each day. 6. Review of staffing schedule for June and July 2023 revealed there were two to three nurses on day shift and two nurses on night shift. There were two to three STNA's on day shift and one to three STNA's on night shift. Interview on 07/06/23 at 2:40 P.M. ED revealed the facility staffed according to census and acuity. ED verified the 400 hall had more residents that required two assist than the other halls. ED stated the Director of Nursing (DON) had to work the floor at times due to staffing but it was less now than in the past. ED also verified the facility had to use staff from sister facilities due to not having enough staff to cover the shifts. ED stated there had recently been a turnover in employees. ED verified she was not aware showers were not being done as scheduled. This deficiency represents non-compliance investigated under Complaint Number OH00143884 and OH00143745. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 16 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure pharmacy recommendations were followed for Resident #23. This affected one resident (#23) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. She received an antidepressant seven days during the look back period. Review of the pharmacy recommendation dated 08/23/22 revealed Resident #3 had orders for Depakote and as needed lorazepam, which could be used for multiple purposes. The pharmacist recommended specifying a reason for use and adding side effect monitoring. The physician agreed with all recommendations. Review of the pharmacist recommendation dated 10/19/22 revealed the pharmacist indicated Resident #23 was on Depakote 125 mg which could be used for multiple purposes. She recommended reviewing and specifying the reason for use to assist with proper use, appropriate behavior monitoring, and care planning. Additionally, a recommendation to add reason for use and add a reevaluation date and rationale for continued use to 'as needed' order of lorazepam. Review of the pharmacist recommendation dated 11/29/22 revealed as needed lorazepam needed to be updated to include an indication for use. The physician agreed with the recommendations. Review of Resident #23's physician order dated 08/16/22 revealed an order for Depakote Sprinkles delayed release 125 mg three times a day. There was no diagnosis indicated for this medication. Interview on 07/03/23 at 4:53 P.M. with Area Executive Director (AED) #82 verified Resident #23's order for Depakote did not have a diagnosis listed. Interview on 07/05/23 at 3:08 P.M. with the Administrator verified the pharmacy recommendations repeated themselves indicating they had not been done. Review of the policy titled 'Medication Regimen Review' revised November 2018, revealed pharmacy recommendation should be acted upon and documented by the facility personnel and or the prescriber. The prescriber either accepts and acts upon the suggestion or rejects and provides an explanation for disagreeing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 17 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 interview and record review the facility failed to ensure as needed psychotropics were limited to 14 days or that the physician documented a rationale for extending the use and provided a duration for use for Resident #9 and Resident #23 and failed to ensure a psychotropic had an indication of use for Resident #9. This affected two residents (#9 and #23) of five residents reviewed for unnecessary medications. The facility census was 36. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 08/16/22 with diagnoses including unspecified dementia, anxiety disorder, depression, anorexia, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was rarely or never understood. Review of Resident #23's physician order dated 12/01/22 revealed an order for Lorazepam 2.0 milligrams (mg) per milliliter (ml) 0.5 ml to be administered every four hours as needed for anxiety there was no end date specified. Interview on 07/05/23 at 3:08 P.M. with the Administrator verified there was no end date for an 'as needed' psychotropic. Review of the policy Psychotropic Medication Usage and Gradual Dose Reductions dated 12/31/22, revealed residents were to receive psychotropic medications only if designated medically necessary by the prescriber, with the appropriate diagnosis or documentation to support its usage. 'As needed' order for psychotropic drugs were to be limited to 14 days, except as provided if the attending physician or prescriber believes that it is appropriate for the 'as needed' order to be extended beyond 14 days. In that case, they should document their rationale in the resident's medical record and indicate the duration for the order. 2. Review of the medical record for Resident #9 revealed an admission date of 07/20/21 with diagnoses including Parkinson's disease, dementia, schizophrenia, obstructive and reflux uropathy, gastrostomy, dysphagia, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was rarely or never understood. He received an antipsychotic, antidepressant, and antibiotic, seven days during look back period. Review of Resident #9's physician order dated 02/10/23 revealed an order for Risperdal 4.0 mg at bedtime daily. There was no diagnosis listed for this medication. Interview on 07/03/23 at 4:53 P.M. with Area Executive Director (AED) #82 verified there was no diagnosis for Risperdal and there should have been. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 18 of 19 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 366475 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Smiths Mill Health Campus 7320 Smiths Mill Road New Albany, OH 43054 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 Review of Resident #9's physician order dated 02/10/23 revealed he was to receive Lorazepam 0.5 mg as needed every four hours for anxiety, there was no end date specified. Interview on 07/05/23 at 3:08 P.M. with the Administrator verified there was no end date for an 'as needed' psychotropic. Residents Affected - Few Review of the policy Psychotropic Medication Usage and Gradual Dose Reductions dated 12/31/22, revealed residents were to receive psychotropic medications only if designated medically necessary by the prescriber, with the appropriate diagnosis or documentation to support its usage. 'As needed' order for psychotropic drugs were to be limited to 14 days, except as provided if the attending physician or prescriber believes that it is appropriate for the 'as needed' order to be extended beyond 14 days. In that case, they should document their rationale in the resident's medical record and indicate the duration for the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366475 If continuation sheet Page 19 of 19