Health inspection·February 26, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #20's ADL plan of care dated 12/12/23 revealed the resident required staff assistance to complete self-care and mobility functional task completely and safely. Offer nail care and facial shaving on shower days and as needed or requested. Notify nursing of refusals. Review of Resident #20's non-compliance plan of care dated 11/28/23 and reviewed/revised on 01/08/24 revealed the resident sometimes refused plan of care as evidenced by she sometimes refuses meals, therapy, weights, to get out of bed, and sometimes refuses showers. The interventions included educating residents regarding the benefits, encouraging them to actively participate in care and make decisions by offering choices, and monitor resident's ability to give informed consent. Review of Resident #20's progress notes dated 11/21/23 to 02/26/24 revealed the resident had refused a shower one time on 01/02/24. Review of Resident #20's bathing documentation dated 11/21/24 (admission date) to 02/26/24 revealed the resident was dependent on staff for bathing. The resident had one shower on 12/13/23, 19 partial bed baths, 15 complete bed baths, and one other during her stay thus far. The resident had refused one bath on 01/02/24. Interview on 02/26/24 at 8:09 A.M. and 12:08 P.M., with Resident #20 revealed she had concerns about not receiving showers per preference. The resident reported she was admitted around Thanksgiving and can count on one hand how many showers she has received. She was supposed to get showers twice a week on Tuesday and Friday. The resident reported she depended on staff for all her ADL's. Last week she had requested a shower because she could smell herself. She did have to refuse a shower once last week after she had requested one to be done due to the aide came when she was with therapy and when she came back the second time, she was doing something and could not recall at this time what it was, however the aide worked Saturday and performed a shower then. The resident reported the facility was short of staff and what staff they have are overworked. Interviews on 02/26/24 from 8:05 A.M. to 3:14 P.M., with Anonymous Staff Members #145 and #179 revealed there has been a shortage of staff recently due to call offs and showers were not being completed per the shower schedule/resident preference. Interview on 02/26/24 at 3:12 P.M., with the Administrator and Corporate Nurse confirmed there was no documented evidence Resident #52 had received a shower during his stay from 01/26/24 to 02/23/24. The Corporate Nurse reported Resident #20 was care planned for sometimes refusing showers, however there was only one day there was documented evidence the resident had refused. The Administrator reported the facility used to have a shower aide, but she had resigned, and showers were now part of the aide's daily task to complete. The Director of Nursing has been off for the last week and a half per the Administrator, and she can't find documented evidence that all the concerns were investigated and addressed. Review of the shower schedule (undated) revealed Resident #20 shower days were Tuesday and Friday on dayshift and Resident #52's was Monday and Thursday on second shift. Review of the resident council minutes dated 01/26/24 revealed residents voiced concerns that they needed more help with showers. The resolution was an all-staff meeting was held the day prior on 01/25/24 and education was provided on personal care expectations and 02/05/24 further education provided to all staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366480 If continuation sheet Page 2 of 5 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 366480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylor Springs Health Campus 748 Taylor Road Gahanna, OH 43230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the Nurses Agenda Meeting notes dated 01/24/24 and 01/25/24 revealed no evidence of education on personal care expectation and there was no evidence of education on 02/05/24. Review of the facility concern log dated 11/01/23 to 02/26/24 revealed Resident #20 had voiced concerns on 11/23/23 dissatisfaction with all aspects of the community's level of care and Resident #52's family voiced concerns they could never find a caregiver. There were five other concerns regarding grooming (showers/shaving). Further review of the concern log revealed no evidence the concerns were investigated and followed up. Review of the facility policies and procedure titled Guidelines for Bathing Preference dated 12/31/23 revealed the resident shall determine their preference for bathing upon admission (day, time of day and type of bathing). Bathing shall occur at least twice a week unless resident preferences state otherwise. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151373. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366480 If continuation sheet Page 3 of 5 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 366480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylor Springs Health Campus 748 Taylor Road Gahanna, OH 43230 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. Based on review of call lights response reports, review of concern logs, interviews, and observation the facility failed to ensure sufficient staffing to provide care and services to residents. This affected three residents (#11, #20, and #52) of four residents interviewed with the potential to affect all 50 residents. Finding included: Observation on 02/26/24 at 8:00 A.M. during the initial tour revealed there were several resident call lights activated on the 100 and 300 halls. Four nurses were observed administering medication and there were four State Tested Nurse Aides providing care. 1. Review of Resident #11's call light response report dated 02/26/24 revealed on 02/26/24 at 4:30 A.M. the call light went off for 22 minutes and two seconds and at 7:01 A.M. it went off 33 minutes and 28 seconds. Interview on 02/26/24 at 8:15 A.M. and 11:10 A.M., with Resident #11 revealed she was just admitted on Thursday, but the call light response time was not always prompt. The resident reported she had to wait half an hour to 45 minutes for someone to answer her call light. Once she waited so long, she forgot what she pushed the call light for. 2. Review of Resident #20's call light response report dated 02/01/24 to 02/26/24 revealed there was 18 times the call light activation ranges were from 10 minutes to 30 minutes. On 02/06/24 at 11:20 A.M. the call light rang 48 minutes and 29 seconds, on 02/10/24 at 9:38 A.M., the call light rang 50 minutes and 51 seconds, on 02/14/24 at 8:31 A.M.,. the call light rang 41 minutes and 29 seconds, at 10:04 A.M. the same day it rang 2 hours, two minutes, and 56 seconds, on 02/16/24 at 7:37 A.M., it rang one hour 30 minutes and 10 seconds, on 02/19/24 at 4:41 A.M. it rang 56 minutes and nine seconds, at 9:32 A.M., the same day it rang 2 hours 33 minutes and 47 seconds, and 02/25/24 at 8:54 A.M. the call light rang 53 minutes and 56 seconds. Interview on 02/26/24 at 8:09 A.M. and 12:08 P.M., with Resident #20 revealed she had voiced concerns regarding call light response time; however, the concern continues and has never been resolved. Staff told her they couldn't see her call light going off outside of her room because the light was dim, but then she found out the call lights went to a pager and lit up at the nurse's station as well. The resident reported on 02/16/24 she had put her call light on at 7:20 A.M. to have staff assist her with getting ready for an appointment that she had to be ready for by 9:30 A.M. Finally, at 8:50 A.M., she had called her sister because staff had not answered her call light. Her sister called the facility to voice concern and the facility staff finally came and helped her. The resident reported she had sat in her own bowel movement for four hours waiting on staff to help her before. The facility was short-staffed and the workers they have were overworked. The nurse will help the aides sometimes, but they have attitude when they have to help. 3. Review of Resident #52's call light response report dated 01/26/24 (admission date) to 02/23/24 (discharge date ) revealed there was four times the residents call light activation ranged from 10 minutes to 30 minutes. On 01/28/24 the call light rang for 32 minutes and three seconds and on 02/07/24 the call light rang 32 minutes and 14 seconds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366480 If continuation sheet Page 4 of 5 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 366480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylor Springs Health Campus 748 Taylor Road Gahanna, OH 43230 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 Interview on 02/26/24 at 9:03 A.M., with Resident #52's family member revealed there were concerns with call lights not being answered timely. The family member observed other call lights going off for extended period and had heard residents calling out for help. The family had reported concerns to the facility but was told they were meeting the staffing requirements. Interviews on 02/26/24 from 8:05 A.M. to 3:14 P.M. with Anonymous staff members #145 and #179 confirmed call lights were not always being answered timely due to staffing issues. Staff were calling off frequently and not being replaced. Interview on 02/26/24 from 12:21 P.M. to 3:14 P.M., the Administrator revealed there had been a few concerns reported regarding delays in call light response times. Staff have been educated and provided one-on-one teachable moments. There have also been changes in staffing including new nurse managers and they had to let a staff member go last week. The Administrator reports that the Director of Nursing had been off a week and half and has the information regarding the follow ups with the concern logs, however she cannot locate the information at this time. The Administrator reported the call light policy doesn't have a time frame for answering call lights, but her expectation would be no more than 30 minutes. The Administrator reviewed the call light response reports with the surveyor for Resident #11, #20, and #52 and confirmed there were several times the call lights went off greater than 30 minutes. The Administrator reported she didn't think the root cause was staffing shortage, but she would have to do more investigating to determine what the root cause of the delay of call response times. The facility was currently full at 50 residents, and they were meeting above the 2.5 requirement for the state level. Review of the concern log dated 11/01/23 to 02/26/24 revealed on 11/23/23 Resident #20 had voiced concerns regarding call light wait time. The Director of Nursing (DON) will meet with residents and call light education will be sent out and addressed. The resident voiced understanding. On 11/29/23 Resident #20 voiced another concern regarding poor call light response time since admission. There was no evidence the concern was addressed. On 02/08/24 Resident #52's family had voiced concerns they can never find caregivers and call light/waiting times. The resolution was education was provided on 01/25/24 and working on call light audits. There was no evidence call lights were discussed on the agenda on 01/25/24 and no evidence of call light audits. There were three other concerns related to call light response times were too long. There was no evidence provided the concerns were investigated or followed up. Review of the facility guidelines for answering call light (dated 12/31/23) revealed to answer resident's call lights as quickly as possible. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number OH00151373. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366480 If continuation sheet Page 5 of 5