Health inspection·March 7, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few However, there was no documented evidence the resident's POA was notified of the change to the hemodialysis days. Review of the facility policy titled, Change in a Resident's Condition or Status, dated 05/2017 revealed the facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). This deficiency represents non-compliance investigated under Complaint Number OH00151273 and Complaint Number OH00151045. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366496 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 366496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allbridge Rehabilitation and Nursing Center 5500 East Broad Street Columbus, OH 43213 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to ensure the safety of Resident #34, who obtained access to a locked employee breakroom to utilize a facility microwave unsupervised. Actual harm occurred on 02/28/24 when Resident #34 sustained second degree burns to his left thigh after spilling hot water on his leg. The injury was a result of Resident #34 entering an employee breakroom with a Styrofoam cup of water where he proceeded to heat the water in the facility microwave without supervision. Upon exiting the breakroom the resident spilled the cup of hot water on his left thigh resulting in second-degree burns (a type of burn that affects the first and second layer of skin. The resident complained of subsequent pain to the area and required a wound care treatment. (Second-degree burns can cause pain, redness, blistering and sloughing of the top layers of skin.). At the time of the incident, the facility failed to ensure the resident did not have access to the area. This affected one (Resident #34) of three residents reviewed for accidents. The facility census was 36. Findings Include: Review of the medical record for the Resident #34 revealed an initial admission date of 12/14/23 with the latest readmission of 02/07/24 with diagnoses including osteoarthritis of left hip, chronic obstructive pulmonary disease (COPD), severe morbid obesity due to excessive calories, insomnia, pain in left leg, hypertension, heart failure, obstructive sleep apnea, benign prostatic hyperplasia with lower urinary tract symptoms, major depressive disorder, anxiety disorder and functional quadriplegia. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident was dependent on staff for transfers, dressing, toileting and required substantial/maximal assistance with personal hygiene. The resident was independent with eating. The assessment indicated the resident was at risk for skin breakdown and had moisture associated skin damage (MASD). The facility implemented the interventions pressure reducing device to bed/chair and application of ointments/medications other than to feet. Review of the incident report dated 02/28/24 at 8:48 A.M. and titled, self-injury, revealed the resident was found to have three fluid filled blisters to the left thigh during weekly skin check. The resident reported he was heating water in the employee lounge microwave in a Styrofoam cup and spilled the hot water on himself. When asked why he was in the employee break room the resident reported he went in on his own. The incident report indicated the resident knew the code to the employee break room door and entered without facility permission or staff knowledge using facility equipment. The facility implemented the interventions offered ice and resident declined, educated the resident on not using the employee break room, and changing the code to the lock. Review of the resident's pain assessment dated [DATE] at 9:14 A.M. revealed the resident had frequent pain rated at a level five out of 10 with 10 being the worst pain possible. Review of the late entry event note dated 02/28/24 at 10:11 A.M. revealed the resident was observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366496 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 366496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allbridge Rehabilitation and Nursing Center 5500 East Broad Street Columbus, OH 43213 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 - Actual harm Residents Affected - Few to have three clear fluid filled blisters to the medical aspect of the left upper leg proximal to the knee. The superior blister measured 4.0 centimeters (cm) by 2.5 cm, the second blister measured 2.5 cm by 3.5 cm and the inferior bladder measured 5.5 cm by 4.0 cm. The blisters remained intact, and the surrounding tissue was red. The areas were cleansed with normal saline (NS), pat dry, abdominal (ABD) pad applied and secured with Kerlix and tape. The resident was medicated with pain medication. Review of the resident's February 2024 Medication Administration Record (MAR) revealed on 02/28/24 at 2:45 P.M., Resident #34 was administered Tylenol 325 milligrams (mg) three tablets by mouth for complaints of pain rated a 10 out of 10 with 10 being the worst pain possible. Review of the physician progress note dated 02/29/24 revealed the resident was seen for burns to left lower thigh. The resident reported he spilled a hot beverage on himself and sustained a burn to the left thigh. The resident had complaints of pain and reported a blister. Upon examination the resident was found with a clearly demarcated area of erythema (abnormal redness of the skin) and a large blister noted within the circumscribe area of erythema. The physician had no concern for infection at that time. The physician provided a treatment order to cleanse the area with NS, pat dry and apply Mupirocin cream twice daily for seven days. The physician also ordered a narcotic analgesic, Oxycodone for pain control, laboratory testing for a complete blood count (CBC) and basic metabolic panel (BMP) and wound team to follow. Review of the interdisciplinary team (IDT) progress note dated 03/03/24 at 7:44 P.M. revealed the resident was observed to have skin impairment to the left thigh. The resident displayed no signs of distress or pain at that time. The resident was offered ice and refused. The physician was notified and the resident would be seen by the wound physician. The resident had a treatment in place and the resident was educated on not going into the break room and the note indicated to have lock code changed. Review of Resident #34's plan of care revealed no care plan addressing the burn to the resident's left upper thigh. Review of the monthly physician orders for March 2024 revealed an order, 02/07/24 for Tylenol 325 mg with the special instructions to administer three tablets every six hours for pain. Orders on 02/29/24 for CBC and BMP, on 03/04/24, dressing change to wound on left upper leg twice daily, wound team to follow up for burn to left leg, Mupirocin external ointment 2% with the special instructions to apply to left leg topically twice daily for wound healing for seven days to burn on upper left leg with dressing changes and Oxycodone 5 mg by mouth every six hours as needed for pain. On 03/05/24 at 11:03 A.M., interview with Resident #34 revealed he had asked an older lady to heat the Styrofoam cup of water and was told to do it himself. Resident #34 revealed the older lady gave him the code to the employee breakroom. On 03/05/24 at 12:00 P.M., observation of Licensed Practical Nurse (LPN) #112 provide the physician ordered treatment to the second-degree burns to Resident #34's left thigh. Observation revealed the LPN set-up the required supplies on a barrier on the resident's bedside table. The LPN washed her hands, donned disposable gloves and removed the soiled dressing. The resident had three open areas within the large erythema area. The open areas were ruptured, fluid filled blisters and the skin was pink in color. The LPN cleansed the open areas with NS and two by two. She then washed her hands, donned a pair of gloves, applied the Mupirocin external ointment 2% to the erythema area, including the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366496 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 366496 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allbridge Rehabilitation and Nursing Center 5500 East Broad Street Columbus, OH 43213 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 ruptured blisters. She then covered the area with an ABD pad and secured the ABD pad with tape. Level of Harm - Actual harm On 03/05/24 at 12:08 P.M., during an interview with Resident #34, the resident provided the surveyor the code to the breakroom and indicated it would open because the facility had not changed the code. Residents Affected - Few On 03/05/24 at 12:11 P.M., observation of the employee breakroom revealed the code given by Resident #34 was placed in the lock and the door opened. The Administrator verified the code to the employee breakroom lock had not been changed allowing Resident #34 continued access to the microwave. This deficiency represents non-compliance investigated under Complaint Number OH00151606. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366496 If continuation sheet Page 5 of 5