Inspection·March 5, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm tube did not include the need to provide any treatment to the nephrostomy tube site that was specified on her discharge orders from the hospital. 2. Review of the medical record for Resident #59 revealed an admission date of 09/07/20. Diagnosis included tracheostomy status, diabetes, and malignant neoplasm at the base of the tongue. Residents Affected - Few Review of Resident #59's quarterly MDS assessment revealed the resident was cognitively intact and had a tracheostomy. Interview on 02/27/24 at 09:51 A.M. Resident #59 revealed he does all his own tracheostomy care. Review of Resident #59's admission care plan dated 09/07/20 revealed the resident did not have a care plan related to tracheostomy care. Continued review revealed revisions up until 02/28/24 did not indicate the resident does his own tracheostomy care. Interview on 02/28/24 at 11:59 A.M. Unit Director #95 revealed Resident #59 has always done his own tracheostomy care since his admission to the facility. She confirmed his admission care plan did not reflect this tracheostomy care and revisions until 02/28/24 did not reflect that he does his own tracheostomy care. Based on interview and record review, the facility failed to develop comprehensive care plans for Resident #30, Resident #59, and Resident #82. This affected three residents (#30, #59, #82) of 27 residents reviewed for comprehensive care plans. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 10/31/23 with diagnoses including spinal stenosis, osteoporosis, cord compression, chronic respiratory failure, type two diabetes mellitus, chronic pain syndrome, ankylosing spondylitis of spine, and gout. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition. Review of Resident #30's plan of care last reviewed 02/12/24 revealed discharge plans were not indicated in the care plan. Interview on 02/26/24 at 3:08 P.M. with Resident #30 revealed he did not plan on staying in the facility long term. Interview on 02/29/24 at 4:14 P.M. with Social Service Designee #4 verified Resident #30's care plan did not include his discharge plans and should have. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 2 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 record review, observation, resident/ responsible party interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed for bathing and other personal hygiene related care. This affected seven (Resident #4, #20, #42, #82, #245, #248, and #253) of nine residents reviewed for activities of daily living (ADL's). Residents Affected - Some Findings include: 1. A review of Resident #20's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included difficulty walking, unsteadiness on her feet, and need for assistance with personal care. She did not have diabetes mellitus listed as a known diagnosis. A review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech and was able to make herself understood and was usually able to understand others. She was cognitively intact and was not noted to have displayed behaviors during the seven days of the assessment period. She was known to reject care during four to six days of the seven day assessment period. She was indicated to have a functional limitation in her range of motion on one side of her upper extremities. Supervision or touching assistance was needed with personal hygiene. A review of Resident #20's care plans revealed she had a care plan in place for being prone to ADL/functional deficits related to acute on chronic health conditions, impaired strength and endurance, weakness, difficulty walking, unsteadiness on feet, acute on chronic back pain with radiculopathy. The interventions included assisting the resident with daily bathing, hygiene, dressing and grooming cares the resident was unable to complete independently as needed daily. A review of Resident #20's bathing documentation under the task tab of the electronic medical record (EMR) revealed the resident's last documented shower was done on 02/19/24. The personal hygiene documentation only documented the level of assist that was provided and did not document what hygiene care had been provided. There was nothing in the EMR that documented the provision of nail care when provided. On 02/26/24 at 11:44 A.M., an observation of Resident #20 noted her to be lying in bed. Her left hand was contracted and she was noted to have several nails on her left hand that were long and in need of being trimmed. The fingernails on those digits were noted to be about an inch longer than the end of her digit. An interview with the resident at the time of the observation revealed she liked to keep her fingernails trimmed short. Ongoing observations of Resident #20 on 02/27/24 at 1:09 P.M., 02/28/24 at 8:43 A.M., 02/29/24 at 1:45 P.M., and 03/04/24 at 9:35 A.M. noted several fingernails to the contracted left hand remained long and in need of being trimmed. The observations on 02/29/24 at 1:45 P.M. noted one of the three fingernails on the left hand was shorter than it was previously noted to be. The resident reported that fingernail had broken off and denied it was shorter as the result of the staff trimming them for her. On 02/27/24 at 2:20 P.M., an interview with State Tested Nursing Assistant (STNA) #14 revealed nail care was provided to residents when necessary. She stated she did not like to trim them as she had cut a resident's skin doing it in the past, but would do it if necessary. She further stated they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 3 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 would just have to make sure the resident was not a diabetic before trimming a resident's fingernails. She confirmed the resident's fingernails on her contracted left hand were long and in need of being trimmed. On 02/27/24 at 4:05 P.M., an interview with Registered Nurse (RN) #112 was conducted and the nurse denied she could see any further documentation to show Resident #20 had been given a bath/ shower after 02/19/24. She acknowledged the resident had some long fingernails on several of her digits on her contracted left hand. She was informed the resident was requesting that they be trimmed. On 03/04/24 at 9:40 A.M., RN #112 was informed Resident #20's fingernails on her contracted left hand had still not been trimmed even after it was brought to her attention on 02/27/24. She was informed the resident reported one of the three nails had since broken off on its own and the resident was requesting a pair of nail clippers to she could trim them herself using her right hand. The nurse made note of the information provided indicating she would follow up on it. A review of the facility's Nail and Foot Care policy effective 01/04/03 revealed the purpose of the policy was to achieve and maintain the highest level of nursing standards of care provision. The policy specified residents would have nail and foot care daily and prn. The procedures included clipping the fingernails straight across using nail clippers to a length that was even with the tops of the fingers. They were then to shape the nails with an [NAME] board or file. 2. A review of Resident #82's medical record revealed the resident was admitted to the facility on [DATE]. She remained in the facility until being discharged home on [DATE]. Her diagnoses included the need for assistance with personal care, unsteadiness on her feet, muscle weakness, repeated falls, fatigue, chronic kidney disease stage 5, dependence on renal dialysis, and osteoarthritis. A review of Resident #82's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. No behaviors or rejection of care was noted. The resident had a functional limitation in her range of motion to her bilateral upper extremities. The resident needed partial/ moderate assist with showers/ baths and needed set up or clean up assistance. A review of Resident #82's care plans revealed she had a care plan in place for being prone to ADL/functional deficits related to acute on chronic health conditions, impaired strength & endurance, weakness, unsteadiness on her feet, recent UTI, and influenza (flu). Her interventions included the need to assist her with daily bathing, hygiene, dressing and grooming cares the resident was unable to complete independently as needed daily. They were to shower/ bathe her per the resident's personal preference. A review of the shower schedule for Resident #82's unit revealed showers were scheduled according to the room numbers. The resident was scheduled to receive a shower every Sunday and Wednesday on the night shift. A review of Resident #82's bathing documentation under the task tab of the EMR (from admission to present) revealed the resident was documented as having received one shower on 02/18/24. A partial bed bath was documented as having been given on 02/11/24. There were no showers or other bathing activities documented as having been provided to the resident on her scheduled shower days for 02/04/24, 02/07/24, 02/14/24, 02/21/24, and 02/25/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 4 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 Additional paper shower sheets had been provided for review by RN #112. She had the paper shower sheets in a binder at the nurses' station or in her office that had not been documented under the bathing documentation under the task tab of the EMR. She found documentation of Resident #82 receiving a bed bath on 02/04/24 and was documented as having done her ADL's in her room herself on that day. There was still no documentation of any bathing activity being provided to the resident on 02/07/24, 02/21/24, or 02/25/24, which were scheduled shower days. On 02/26/24 at 4:26 P.M., an interview with Resident #82 revealed she did not get assisted with receiving showers twice a week as she was scheduled. She indicated she was typically only being showered once a week since she had been in the facility. On 02/27/24 at 4:05 P.M., an interview with RN #112 revealed she was not able to find any additional documentation to support Resident #82 was being showered twice a week as scheduled. She indicated if it was not documented under the task tab in the EMR or on one of the paper shower sheets she provided then the resident did not receive a shower on the three days above (02/07/24, 02/21/24, or 02/25/24) in which a shower was not documented as having been provided on her scheduled shower days. A review of the facility's policy on Bathing a Resident effective 04/20/12 revealed it was the policy that all residents were made aware of bathing options and would be offered choice of bathing preference including when and how often they were bathed. 3. A review of Resident #248's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease, difficulty in walking, unsteadiness on his feet, need for assistance with personal care, muscle weakness, and depression. A review of Resident #248's care plans revealed he had a care plan in place for being prone to ADL/functional deficits related to acute on chronic health conditions. His interventions included assisting the resident with daily bathing, hygiene, dressing and grooming cares the resident was unable to complete independently as needed daily. They were to provide set up/ assistance as needed to shave per the resident's personal preference. They were to shower/ bathe the resident per his personal preference. His care plans did not reveal he was resistive to care. A review of the facility's shower schedule for Resident #248's unit revealed showers were assigned based on the residents room numbers. Resident #248 was to receive showers on Tuesdays and Fridays on the day shift. A review of Resident #248's bathing documentation under the task tab of the EMR revealed the resident was not documented as having received any type of bathing activity since his admission to the facility on [DATE]. There was nothing documented as having been provided to the resident on 02/23/24 (Friday), which was his scheduled shower day. On 02/26/24 at 4:43 P.M., an observation of Resident #248 noted him to be lying in bed in a supine position with the head of bed elevated. His hair was greasy and uncombed. He was also noted to have long facial hair and his fingernails were long and dirty. An interview with the resident at the time of the observation revealed he did not like facial hair and preferred to be clean shaven. Ongoing observations of Resident #248 on 02/27/24 at 1:05 P.M., noted the resident's hair remained greasy/ uncombed, and he remained unshaven and his fingernails remained long and had a dark colored substance under the ends of his fingernails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 5 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 On 02/27/24 at 2:20 P.M., an interview with STNA #200 revealed Resident #248 was a day shift shower and would need staff assistance to perform any personal care. They documented showers on paper shower sheets or in the computer when they were provided. She was informed there was nothing documented in the computer to show a shower or some other type of bathing activity had been provided to the resident since his admission. She also acknowledged the resident was unshaven reporting yesterday that he liked to be clean shaven and his fingernails were long and dirty. She denied she had attempted to bathe, shave, or trim the resident's fingernails since he had been in the facility. On 02/27/24 at 3:55 P.M., an interview with RN #112 revealed they did not have any documented evidence of Resident #248 having been provided a shower or assisted with shaving, or nail care since he had been admitted to the facility on [DATE] (5 days). She did not have any documentation to support the resident had been offered and refused a shower/ bath on 02/23/24 when it was his scheduled shower day. She did provide a paper shower sheet for a bathing activity that was provided to the resident on 02/27/24 in which he was indicated to have refused a shower but was given a bed bath instead. The paper shower sheet did not document anything about nail care or shaving as having been completed as part of the bathing activity provided. A review of the facility's policy on Shaving a Resident effective 01/05/03 revealed it was the policy of the facility for residents to be shaved daily and prn. 4. A review of Resident #253's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included a right knee replacement, unsteadiness on his feet, need for assistance with personal care, and vascular dementia. A review of Resident #253's care plans revealed he had a care plan in place for being prone to ADL/functional deficits related to acute on chronic health conditions. His interventions included the need to assist with daily bathing, hygiene, dressing and grooming cares the resident was unable to complete independently as needed daily. They were to provide set up/ assist as needed to shave per the resident's personal preference, set up/ assist as needed with oral care every morning, after meals and at bedtime per residents personal preference, and to shower/ bathe the resident per his personal preference. His care plans did not reveal he was known to be resistant to personal care. A review of the facility's shower schedule for Resident #253's unit revealed showers/ bathing activity was assigned based on the resident's room number. His shower days were scheduled for Sundays and Wednesdays on the evening shift. A review of Resident #253's bathing documentation under the task tab of the EMR revealed the resident was marked as having refused a bathing activity when offered on 02/22/24 (day after admission). There was no indication of any additional bathing activities being attempted since. The personal hygiene documentation under the task tab only indicated what assistance level was needed and not what personal hygiene activities had actually occurred. There was no documentation to show when/ if he had been shaven since admission, or if oral care was being provided as part of his personal care. On 02/26/24 at 2:22 P.M. an observation of Resident #253 noted him to be lying in bed in a supine position with the head of the bed elevated. He was unshaven and had halitosis (bad breath). An interview with the resident's power of attorney (POA) at the time of the observation revealed he did not think the resident had been showered since he had been admitted into the facility. The POA stated he had brought the resident a tooth brush and toothpaste but neither had been used since he brought them. He indicated the resident had also not been shaved and liked to be clean shaven. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 6 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 On 02/27/24 at 2:15 P.M., an interview with STNA #39 revealed she had worked at the facility for about two months now. They had a computer that provided them with each resident's care plan so they knew the care needs of each resident. She was asked how much assistance Resident #253 needed with his personal care. She indicated he needed help washing himself up. She felt he was able to do his upper body but they would have to wash his lower body for him. She stated his scheduled showers were to be done on the night shift. He would get two a week unless there was a request to receive more. She reported she would do morning (am) care for the resident in addition to any scheduled baths/ showers to include washing his face and hands. She described the resident as being confused, but cooperative. She indicated he could not express his preferences on whether or not he wanted facial hair. She would ask the caregiver since the resident could not answer. She denied that the resident or the caregiver had asked him to be shaved. She claimed the caregiver liked how things were. She was then asked about the resident's dental status. She did not think he had any of his own natural teeth, but then said she had never actually seen his teeth to know if he had any or not. When asked how she provided oral care to the resident she replied she just swabbed his mouth out with a toothette. She was informed the resident did respond yesterday when asked what his preference was on the presence of facial hair and made it known that his preference was to be clean shaven. She was surprised that the resident was able to express his preference when asked. She was also informed the caregiver/ POA verbalized concerns of the resident not having been given a bath/ shower during the six days that he had been there. She was further informed the resident had halitosis when observations and conversations were had with the resident on 02/26/24 and again on 02/27/24 and the caregiver/POA denied anyone was brushing his teeth. Two tooth brushes were found in his bathroom and both had bristles that were dry and the tooth brushes were like new. There was a facility issued tube of toothpaste and another tube of toothpaste that the caregiver/ POA had brought in. The caregiver reported there had not been any toothpaste squeezed out of either toothpaste tubes that were found in his bathroom. On 02/27/24 at 4:05 P.M., an interview with RN #112 revealed she could not find any additional documentation on in the computer or on paper shower sheets to support the resident was provided a shower/ bath on 02/25/24 as scheduled. She also acknowledged concerns with the resident not having been shaved since his admission to the facility six days ago, when it was his preference to be clean shaven. She further acknowledged concerns from the resident's caregiver/ POA that he had not been assisted with oral care, as evidenced by halitosis being noted the past couple of days, and the caregiver reporting that he had brought in toothpaste and a toothbrush that had not been used. She was made aware the aide interviewed was unaware of the resident having any natural teeth and had indicated she had been using a toothette to swab the resident's mouth instead of brushing his natural teeth with the oral care supplies he had been provided that was stored in his bathroom. A review of the facility's policy on Tooth Brushing effective 06/11/03 revealed it was the facility's policy for them to practice proper technique when providing mouth care. It was the nurse's responsibility to determine the frequency with which residents require brushing. 5. Review of the medical record for Resident #42 revealed an admission date of 12/16/21 with diagnoses including cerebral infarction, contracture of right hand, dysphagia, aphasia, depression, osteoarthritis, cognitive communication deficit, hemiplegia and hemiparesis affecting right dominant side. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition. She had upper extremity and lower extremity impairments on one side. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 7 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 Resident #42's plan of care dated 10/18/22 revealed they were prone to activity of daily living or functional deficit related to hospitalization, dysphagia, right hemiparesis, diabetes, admission with dependence on others to anticipate and meet needs, impaired strength and poor endurance, balance deficits, and immobility. Interventions included anticipating and meeting needs on an ongoing daily basis, assisting with daily bathing, hygiene, dressing, and grooming cares resident is unable to complete independently as needed daily, therapy as needed, and showering and bathing per preference. Review of Resident #42's assessment titled Functional Abilities and Goals dated 12/06/23 revealed she was dependent for personal hygiene. Observation on 02/26/24 at 11:52 A.M. of Resident #42 revealed her nails on both hands were long and observed to be caked with a brown substance. Interview with Resident #42 verified her nails were longer than she preferred and not clean. Interview on 02/26/24 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #123 verified Resident #42's nails needed cut and cleaned. She reported she was able to clean them but could not cut them as Resident #42 was diabetic and the nurse would need to cut them. Interview on 02/26/23 at 12:07 P.M. with Registered Nurse (RN) #120 verified it was a nurse's responsibility to clip the finger nails of diabetic residents as needed. 6. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including chronic pulmonary embolism, anemia, heart failure, need for assistance with personal care, and adult failure to thrive. Review of MDS completed on 01/24/24 revealed Resident #4 was cognitively intact, had impairment to bilateral upper extremities, required moderate assistance for oral hygiene, maximum assistance for bathing, maximum assistance for dressing, and maximum assistance for personal hygiene. Resident #4 discharged from the facility on 02/12/24. Review of care plan dated 01/19/24 revealed Resident #4 was prone to functional deficits related to acute and chronic health conditions and would obtain optimal level of independence with skilled therapy services to enable return to community living. Interventions included assistance with daily bathing, hygiene, dressing, grooming care needs and to shower and bathe per Resident #4's personal preferences. Review of occupational therapy notes revealed Resident #4 had a goal of improving ability to bathe self, including washing, rinsing, and drying self safely and efficiently with partial to moderate assistance with the use of a long-handled shower head, long handled sponge, and a shower chair in order to return to prior level of living and ensure safe return to prior level of function. Review of a shower schedule revealed Resident #4 was schedule to receive showers during day shift on Mondays and Thursdays. Review of shower sheets revealed Resident #4 received a partial shower on 01/25/24, a bed bath on 02/01/24, and refused a shower on 02/02/24. There were no documented attempts for showers on 01/22/24, 01/29/24, 02/05/24, or 02/08/24. Interview on 03/04/24 at 8:51 A.M. with Assistant Director of Nursing (ADON) confirmed Resident #4 was not offered showers as scheduled. 7. Record review revealed Resident #245 admitted to the facility on [DATE] with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 8 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 difficulty in walking, nonrheumatic aortic valve stenosis with insufficiency, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care, and end stage renal disease. Review of MDS completed on 12/12/23 revealed Resident #245 was cognitively intact, required moderate assistance for bathing, moderate assistance for dressing, and maximum assistance for transfers to the shower. Resident #245 discharged from the facility on 01/04/24. Review of care plan dated 12/07/24 revealed Resident #245 was prone to functional deficits related to acute and chronic health conditions, impaired strength, weakness, difficulty in walking, and cardiac surgery with a goal of transferring independently upon discharge from therapy. Interventions included assist with daily bathing, hygiene, dressing and grooming care as resident is unable to complete independently, and shower or bathe per residents' personal preference. Review of a shower schedule revealed Resident #245 was scheduled to receive showers on Mondays and Thursdays. Review of shower sheets revealed Resident #245 received a bed bath on 12/07/23, a shower on 12/11/23, a shower on 12/18/24, a partial bath on 12/19/23, refused a shower on 12/26/23, and had a shower on 01/04/24. There were no documented attempts to offer showers on 12/14/23, 12/21/23, 12/28/23, or 01/01/24. Interview on 03/04/24 at 8:48 A.M. with ADON confirmed Resident #245 did not receive showers as scheduled. Review of a policy titled Bathing a Resident dated 04/20/12 revealed all residents and families are made aware of bathing options and are offered a choice of bathing preference including when and how often they are bathed. Staff should offer choice of frequency and preference of time upon admission, transfer, quarterly, and as needed or requested. This deficiency represents non-compliance investigated under Master Complaint Number OH00151376, Complaint number OH00151256, and Complaint Number OH00151122. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 9 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 interview, record review, and policy review the facility failed to sufficiently identify and provide activities of interest to Resident #3, specifically on the weekend. This affected one resident (#3) of one resident reviewed for activities. The facility census was 93. Residents Affected - Few Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's activity assessment dated [DATE] revealed she found it somewhat important to listen to music, do things with groups of people, and go outside. She did not find it important to read books, participate in religious services or keep up with the news. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #3's plan of care dated 06/19/23 revealed Resident #3 had little, or no activity involvement related to diagnoses. She was dependent on staff and regular family visits for meeting her physical, social, and sensory needs. The daughter had asked staff to leave the television on for background noise, nothing loud. Interventions included encouraging the resident's family members to attend activities with resident, monitor for impact of medical problems on activity level, remind the resident that they are not required to stay for entire activity, provide assistance to activity functions, and the residents preferences included socializing with family and watching television. Resident #3's medical record revealed no evidence of the kinds of music she enjoyed listening to, what kind of groups she enjoying doing things with, or how and how often these activities would be delivered. Review of Resident #3's activity documentation from 02/01/24 to 02/27/24 revealed Resident #3 received no activities on four out of four Sunday's and on four out of four Friday's. Resident #3 only received activities on two of the four Saturdays of the month. Interview on 03/04/24 at 9:45 A.M. with Activities Lead #44 verified Resident #3 had limited to no activities on Friday and the weekends. He reported that currently, weekend activities were done on a volunteer basis. Activities Lead #44 reported he was the only one coming in and it was every other weekend. Activities Lead #44 verified the activity assessment dated [DATE] was the most recent and thorough assessment completed for Resident #3. He reported this assessment was done quarterly and annually. Review of the policy Activity/Community Life Program revised 12/18/18, revealed activities should be scheduled seven days a week and residents were to be given an opportunity to contribute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 10 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure Resident #4's weights were monitored and addressed timely related to cardio-pulmonary complications and failed to ensure Resident #245's surgical wound and anemia was monitored and properly treated. This affected two residents (Resident #4 and Resident #245) of three residents reviewed for quality of care. Residents Affected - Few Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including chronic pulmonary embolism, anemia, heart failure, need for assistance with personal care, and adult failure to thrive. Review of MDS completed on 01/24/24 revealed Resident #4 was cognitively intact, had impairment to bilateral upper extremities, required moderate assistance for oral hygiene, maximum assistance for bathing, maximum assistance for dressing, and maximum assistance for personal hygiene. Resident #4 discharged from the facility on 02/12/24. Review of orders revealed an order dated 01/19/24 to obtain Resident #4's weight and record in Point Click Care every Monday, an order dated 01/19/24 to obtain Resident #4's weight and record in Point Click Care once daily for three days with a stop date of 01/23/24, and an order dated 01/19/24 to weight Resident #4 daily and record and notify provider of a two pound weight gain within 24 hours once a day for congestive heart failure. Review of a care plan dated 01/19/24 revealed Resident #4 was prone to cardio-pulmonary complications related to acute and chronic health conditions, chronic pulmonary embolism, and heart failure with a goal to be free from cardio-pulmonary complications through goal date of 04/18/24. Interventions included monitoring vital signs as scheduled and as needed, and to weigh as ordered. Review of weight documentation revealed Resident #4 was weighed on 01/18/24, 01/23,24, 01/24/24, 02/01/24, 02/04/24, 02/05/24, 02/08/24, 02/09/24, 02/10/24, and 02/11/24. Resident #4 was not weighed the additional 15 days she was in the facility. Review of weight from 02/04/24 revealed Resident #4 weighed 90.5 pounds and on 02/05/24 Resident #4 weighed 94.6 pounds. Review of nursing notes revealed no evidence a provider was notified Resident #4's weight gain of more than two pounds within a 24-hour period. Interview on 03/04/24 at 10:51 A.M. with Assistant Director of Nursing (ADON) confirmed Resident #4 was not weighed daily per orders and a provider was not notified of a weight gain. 2. Record review revealed Resident #245 admitted to the facility on [DATE] with diagnoses including difficulty in walking, nonrheumatic aortic valve stenosis with insufficiency, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care, and end stage renal disease. Review of MDS completed on 12/12/23 revealed Resident #245 was cognitively intact, required moderate assistance for bathing, moderate assistance for dressing, maximum assistance for transfers to the shower, and had a surgical incision. Resident #245 discharged from the facility on 01/04/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 11 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of hospital discharge instructions from 12/06/23 for Resident #245 revealed wound care instructions to sponge bath or take showers only, cleanse incision with soap and water one to two times a day, pat the incision dry and leave open to air, allow the incision to form a scab and heal, monitor for signs of infection including redness, streaking, swelling, or fever and to keep the incision clean and dry. Review of a nursing note from 12/06/23 at 5:36 P.M. revealed Resident #245 admitted to the facility from the hospital after having a midsternal surgery. Review of care plan dated 12/07/23 revealed Resident #245 was at risk for skin breakdown and development of pressure ulcers related to acute and chronic health conditions, impaired strength, endurance, weakness, difficulty in walking, unsteadiness on feet, cardiac surgery, anticoagulant use, potential edema, and medication injections as well as having a surgical incision to sternal area. The goal was to be free of clinical signs of skin breakdown through the goal date of 03/05/24. Interventions included administering treatments as ordered, monitor for side effects, and to monitor skin with daily care for redness, blisters, and dark discolorations. Review of a Treatment Administration Record (TAR) from December 2023 revealed there were no orders for wound care upon admission to the facility. On 12/14/23, treatment orders were initiated to monitor incision to check for signs and symptoms of redness, tenderness, warmth and drainage every shift related to encounter for surgical aftercare following surgery on the circulatory system starting and to wash incision to chest with soap and water, pat dry and leave open to air to form scabs to heal every day and night shift related to encounter for surgical aftercare following surgery on the circulatory system. Interview on 03/04/24 at 8:48 A.M. with ADON confirmed wound care orders were received from the hospital on [DATE] but were not started until 12/14/23. 3. Record review revealed Resident #245 admitted to the facility on [DATE] with diagnoses including difficulty in walking, nonrheumatic aortic valve stenosis with insufficiency, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care, and end stage renal disease. Review of MDS completed on 12/12/23 revealed Resident #245 was cognitively intact, required moderate assistance for bathing, moderate assistance for dressing, maximum assistance for transfers to the shower, and had a surgical incision. Resident #245 discharged from the facility on 01/04/24. Review of a care plan dated 12/13/23 revealed Resident #245 had anemia with a recent diagnosis of acute blood loss anemia with a goal to remain free of signs and symptoms or complications related to anemia through the review date on 03/05/24. Interventions included administer medications as ordered, monitor for side effects and effectiveness, obtain medication orders as needed, obtain and monitor lab or diagnostic work as ordered and report results to the physician, and to monitor for signs and symptoms of anemia including pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feeling cold, low hemoglobin, shortness of breath on exertion, sore tongue, chest pain, tinnitus, or changes in condition. Review of orders revealed Resident #245 had an order dated 12/06/23 to check hemoglobin level one time only for anemia with a stop date of 12/07/23, an order dated 12/16/23 to check hemoglobin weekly one time a day every Friday for anemia with no end date, and an order dated 12/20/23 for a Comprehensive Metabolic Panel (CMP) and Basic Metabolic Panel (BMP) one time only for anemia and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 12 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hypertension with an end date of 12/21/23. An additional order was in place dated 12/06/23 with a start date of 12/08/23 for Darbepoetin Alfa Injection solution prefilled syringe 40 micrograms/0.4 milliliters inject 0.4 milliliters subcutaneously one time a day every Friday for severe anemia. Review of labs to obtain hemoglobin dated 12/07/23 revealed Resident #245 had a hemoglobin value of 8.1 which was low, and a reference range should be 12 to 16 for anemia. Review of labs to obtain hemoglobin dated 12/21/23 revealed Resident #245 had a hemoglobin level of 9.3 which was low. There was no evidence labs were completed as ordered for 12/29/23. Review of Resident #245's Medication Administration Record revealed she received the injection of Darbepoetin Alfa solution on 12/08/23, missed the dose on 12/15/23, missed the dose on 12/22/23, and to see nurses notes regarding dose due on 12/29/23. Review of nursing notes from 12/29/23 revealed no additional information. Interview on 02/29/24 at 8:46 A.M. with Director of Nursing (DON) confirmed labs were not completed as ordered on 12/29/23 and the medication was not administered as ordered on 12/15/23 or on 12/22/23 despite lab value for anemia indicating Resident #245's hemoglobin was low. DON stated there were no parameters listed in the order for the medication related to hemoglobin levels and the labs should have been completed weekly. A policy titled Medication Administration dated 08/13/21 revealed all necessary assessments should be completed prior to medication administration, all administrations and related assessment findings should be documented, and to check the medications for the right patient, medication, dose, time, and route. This deficiency represents non-compliance investigated under Master Complaint number OH00151376 and Complaint Number OH00151256. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 13 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's 802 matrix, review of the wound physician's wound evaluations, staff interview, and policy review, the facility failed to ensure a resident's wound on his buttocks was properly assessed and classified to identify it as a pressure ulcer as indicated by the wound physician and not moisture associated skin dermatitis as indicated by the facility's wound nurse. This affected one (Resident #249) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: A review of Resident #249's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following CVA (stroke) affecting the right dominant side, aphasia (difficulty with speech), difficulty walking, unsteadiness on his feet, and the need for assistance with personal care. A review of Resident #249's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was not marked as having any pressure ulcers at the time the MDS assessment was completed. He was identified as being at risk for pressure ulcers, but was not identified as having an unhealed pressure ulcer. He was also not indicated to have MASD at the time the admission MDS assessment was completed. A review of Resident #249's care plans revealed he had a care plan in place place for being at risk for skin breakdown. The care plan was updated to reflect he had a right buttock abrasion/ skin tear. The care plan was initiated on 12/05/23 (day after the resident's admission). None of the resident's active care plans identified him as having any known pressure ulcers. A review of Resident #249's skin and wound evaluations under the assessment tab of the electronic medical record (EMR) revealed the resident had a skin and wound evaluation dated 02/09/24 that identified him as having moisture associated skin dermatitis (MASD) to his right gluteus (buttock). The skin and wound evaluation indicated the wound had been present since admission and measured at 0.8 centimeters (cm) x 0.7 cm with a surface area of 0.4 cm2. There were no skin and wound evaluations found in the EMR for any prior assessments completed before 02/09/24 despite the wound having been indicated to be present upon the resident's admission to the facility on [DATE]. Subsequent assessments completed on 02/12/24 and again on 02/23/24 continued to classify the wound as being moisture associated skin dermatitis. A review of Resident #249's physician's orders revealed the resident had an order added on 01/24/24 for the use of Triad Hydrophilic Wound Dress External Paste. The instructions was to apply the paste to his sacrum topically twice a day for wound care. Prior to that order, he had an order for the use of HydraGuard moisture barrier cream topically to his buttocks with incontinence care. That order had been in place since 12/04/23. A review of Resident #249's progress notes for the past 30 days revealed there was no mention of the resident having any skin issues other than mention of redness to the coccyx that had a treatment in place. A review of the facility's 802 matrix revealed the resident was identified as having a stage III pressure ulcer (full thickness tissue loss in which subcutaneous fat may be visible, but bone, tendon, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 14 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or muscle was not exposed; slough may be present but did not obscure the depth of tissue loss). The indication of the presence of a stage III pressure ulcer was not supported by any documentation that was accessible in the resident's EMR. On 02/28/24 at 8:18 A.M., an interview with Registered Nurse (RN) #112 revealed Resident #249 did have a wound to his right buttock. She was asked if the wound was classified as a pressure ulcer or another type of wound. She stated it was classified as MASD. She was not sure why the 802 matrix had him as having a Stage III pressure ulcer as that was the only area he had. She indicated it was developed in the facility and not present upon admission as was indicated on the skin and wound assessment. She stated she took pictures of the area last Friday (02/23/24) and it was in the computer under the skin and wound assessment tab. On 02/28/24 at 8:33 A.M., an interview with Licensed Practical Nurse (LPN) #16 revealed Resident #249 did not have any pressure ulcers that she was aware of. She indicated he did have a little scratch on his buttocks when he first came into the facility. She alleged she had looked at it last Sunday (02/25/26) when she assisted with changing the resident and there was nothing there. They continue to apply a barrier cream to his buttocks with incontinence episodes. On 02/28/24 at 9:15 A.M., the facility's Director of Nursing (DON) provided a copy of the skin and wound evaluation for the area to Resident #249's right gluteus dated 02/23/24. The skin and wound evaluation had been changed to reflect the previously identified area to the right gluteus was now being classified as an unstageable pressure ulcer. On 02/28/24 at 9:16 A.M., an interview with the DON revealed the facility initially assessed the area to Resident #249's right buttock as MASD upon his admission to the facility. He indicated it was seen two days later by the physician and was classified as an unstageable pressure ulcer. He confirmed he had went in and changed the classification of the wound on the skin and wound evaluations that had been completed on 02/09/24, 02/12/24, and 02/23/24 from being MASD to being an unstageable pressure ulcer as that was what was indicated by the physician. He confirmed he made those changes that day before he provided the skin and wound assessment dated [DATE] for review at 9:15 A.M. He also provided an updated care plan for the resident's risk for skin breakdown and development of a pressure ulcer that showed he had a stage III pressure ulcer to his sacral area that had been revised on 02/28/24. The care plan also showed the right buttock abrasion/ skin tear had been healed that was not previously identified as being healed. He reported there was a wound evaluation tab in the computer that the surveyors did not have access to, but was where the wound physician's wound evaluations were documented. He indicated he would provide a copy of the wound physician's wound evaluations and management summaries that had been completed for review. He would also provide a timeline of the pressure ulcer to show it's date of origin and the management of it throughout his stay. A review of a Wound Evaluation and Management Summary for a visit on 01/17/24 revealed the wound physician was asked to see Resident #249 at the request of the referring provider for a thorough wound care assessment and evaluation. His chief complaint indicated the resident presented with a wound on his sacrum. The wound physician assessed the wound as having pressure as the etiology and staged it as an unstageable pressure ulcer with necrosis (a full thickness pressure injury in which the base was obscured by slough and/ or eschar). The duration of the wound was indicated to be greater than one day. It measured 4 cm x 8.5 cm x 0.1 cm. The surface area was 34 cm2. Light serous exudate was noted and the wound bed had 30% thick adherent devitalized necrotic tissue, 50% slough, and 20% skin. Treatment orders were initiated for the use of Triad paste twice a day for 30 days and to limit the amount of time for the resident to be up in his chair to 60 minutes. They were also to provide him (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 15 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with a low air loss mattress and to upgrade his off-loading chair cushion. Debridement of the wound had been performed with the wound physician's next visit on 01/24/24 and the wound was then classified as a stage III pressure ulcer as a result of that debridement and the removal of the necrotic tissue. The wound physician continued to assess the resident's pressure ulcer weekly thereafter continuing to assess it through February 2024 as being a stage III pressure ulcer. His last assessment of the wound was completed on 02/28/24 where he classified it as a stage III pressure ulcer that measured 1 cm x 0.5 cm x 0.1 cm. At that time, 40% of the wound bed was covered with slough, 30% was granulation tissue and 30% was other viable tissue such as dermis or subcutaneous tissue. It was showing signs of healing as evidence by a decrease in the surface area. On 02/28/24 at 10:10 A.M., a follow up interview with the DON revealed he reviewed Resident #249's medical record and developed a timeline for the area the resident had on his buttocks. He denied the resident had anything present prior to 01/16/24. On 01/16/24, the facility noted him to have an area to his buttocks and they put a treatment of Calmoseptine in place. He stated they believed the area to be MASD at that time as he observed it personally and felt that was what the wound should be classified as. On 01/17/24, the resident was seen by wound care physician (who visited the facility) and classified the wound as an unstageable pressure ulcer. He was seen again by the wound physician on 01/24/24 who then classified the wound as a stage III pressure ulcer, after surgical wound debridement had been performed. A treatment for Triad was put in place on 01/24/24, while the use of Calmoseptine was discontinued. He stated the wound physician's most recent visit was on 02/28/24 still classified the wound as a stage III pressure ulcer and Triad paste continued as the treatment. He acknowledged the facility's wound assessments that were done on 02/09/24, 02/12/24, and 02/23/24 were classifying the wound on the buttocks as MASD. He acknowledged there was no facility assessments on a skin and wound evaluation assessment prior to 02/09/24, when the wound had been known to be present since 01/16/24. He reported the wound physician was assessing the resident's wound weekly since it originated on 01/16/24. The facility's wound nurse rounded with the wound physician weekly, with the exception of the 01/17/24 visit due to her being off work. He indicated the facility's wound nurse should be doing the facility's assessment at the time the wound physician evaluated the wound and should ensure their assessments were consistent regarding the classification of the wound and it's measurements. He was not able to explain why the facility's wound nurse was classifying the wound as a MASD when the wound physician was calling it a pressure ulcer. He stated he would not be able to go in and see who had completed the skin and wound evaluations on 02/09/24, 02/12/24, or 02/23/24, as it would now reflect his name, since he went in on those three assessments and changed the classification of the wound from being MASD to a stage III pressure ulcer on all three of those assessments. His name would now appear as the one who had completed those assessments since he revised them even though he was not the one who completed the assessments. A review of the facility's policy on Wound and Skin Program revised 05/30/13 revealed the facility's skin team would assess, measure, and document on all pressure ulcers. The skin team would consist of the wound care nurse, the certified nurse practitioner, and the DON as needed. The resident's physician/ CNP would be contacted with recommendations for treatment orders. The skin team followed the Clinical Practice Guideline on the Treatment of Pressure Ulcers published by the U.S. department of Health and Human Services. The skin team would make decisions about treatment for wounds in the facility. The team may also make recommendations for consults to other professionals as needed. Pressure ulcers were to be staged using the National Pressure Ulcer Advisory Panel definitions. This deficiency represents non-compliance investigated under Complaint Numbers OH00151376, OH00151256, and OH00151122. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 16 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow occupational therapy recommendations and physician orders for splints. This affected two residents (#3 and #42) of four residents reviewed for position and mobility. The facility census was 93. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 was rarely or never understood. Review of Resident #3's plan of care dated 10/14/22 revealed the resident was at risk for or prone to the development of contractures related to pain and immobility. Interventions included providing positioning and splinting to affected joints as ordered and therapy to evaluate and treat as ordered. Review of Resident #3's occupational therapy Discharge summary dated [DATE] revealed discharge recommendations included continuing the left upper extremity passive range of motion program with splinting for left hand and elbow to reduce contracture at two hours with self-care skin checks. Review of Resident #3's physician order dated 02/27/24 revealed an order to encourage staff to don hand roll splint for the left palm, hand, and wrist for two hours as tolerated to reduce severity for current contractures. Review of Resident #3's medical record from 12/06/23 to 02/27/24 revealed no documentation indicating Resident #3's hand splint was in place. Interview on 02/28/24 at 10:41 A.M. with Unit Manager #95 verified the order for the splint had been started the day before. She verified the recommendation was older and it had not been in the medical record to ensure and monitor the splint in place. 2. Review of the medical record for Resident #42 revealed an admission date of 12/16/21 with diagnoses including cerebral infarction, contracture of right hand, dysphagia, aphasia, depression, osteoarthritis, cognitive communication deficit, hemiplegia and hemiparesis affecting right dominant side. Review of Resident #42's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderately impaired cognition. She had upper extremity and lower extremity impairments on one side. Review of Resident #42's plan of care dated 12/17/21, revealed she was at high risk for development of contractures related to hospitalization, dysphagia, and right hemiparesis. Interventions included providing positioning and splinting to affected joints as ordered and therapy to evaluate and treat as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 17 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #42's physician order dated 12/17/22 revealed the resident was to wear a right upper extremity palmar hand orthotic splint. It was to be put on for two to four hours after breakfast and removed prior to lunch. Observation on 02/26/24 at 9:30 A.M., 9:50 A.M., 10:10 A.M., and 11:52 A.M. revealed Resident #42 did not have any splints on. Interview with Resident #42 at 11:52 A.M. revealed she was supposed to have a splint for her right hand, but she could not remember the last time it was in place. Interview on 02/26/24 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #123 verified Resident #42 was not wearing the splint. She reported she was unfamiliar with the unit and had not been aware she was supposed to wear a splint. Interview on 02/26/24 at 12:07 P.M. with Registered Nurse (RN) #120 revealed Resident #42 had been wearing the splint when she arrived that day around 6:30 A.M. RN #120 stated Resident #42 had asked them to be removed at that time. RN #120 reported she believed Resident #42 wore the splint overnight but verified that was not what the order stated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 18 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 record review, observation and interview the facility failed to ensure padded side rails were implemented as ordered for Resident #46 with a history of epilepsy. This affected one resident (Resident #46) of six residents reviewed for accident hazards. The facility census was 93. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/03/2020 with diagnoses that included epilepsy, functional quadriplegia, and stenosis of larynx. Review of the most recent Minimum Data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #46 has a diagnosis of epilepsy, is severely cognitively impaired and is dependent on two person staff assist for personal care. Review of physician orders for Resident #46 revealed an order dated 01/05/2020 for seizure precautions padded side rails every shift. Review of Resident #46 care plan dated 01/22/24 revealed a problem of seizure activity with an intervention of padded bilateral side rails as ordered. Observations of Resident #46's room on 02.27.24 at 9:26 A.M. and 5:01 P.M. revealed Resident #46 was lying in bed and bilateral padded side rails were not implemented. Observation of Resident #46 room on 02/28/24 at 11:57 A.M. with Licensed Practical Nurse (LPN) #95 revealed Resident #46 was lying in bed and bilateral padded side rails were not implemented. LPN #95 verified the lack of padded side rails at the time of discovery. Interview on 02/28/24 at 12:18 P.M. with the Administrator and LPN #95 confirmed resident had an order for padded bilateral side rails and should have been implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 19 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident #82's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included an encounter for surgical aftercare following surgery on the genitourinary system, chronic kidney diseasestage 5, dependence on renal dialysis, artificial openings of urinary tract status, and need for assistance with personal care. A review of Resident #82's After Visit Summary (discharge orders) from the hospital revealed it included a section for wound care/ line instructions for drain/ site/ lines. The scheduling instructions for nephrostomy tube care revealed she was instructed to care for her nephrostomy tube that went into her kidney as she had been instructed. The patient education handout was to be used as a guide on how to complete nephrostomy tube care. The nephrostomy tube care instructions indicated they were to clean area around the nephrostomy tube with soap and water every day. The dressing around the nephrostomy tube was to be changed about every three days or when it got wet or dirty. A review of Resident #82's physician's orders revealed there were orders in place to monitor the left nephrostomy for signs and symptoms of infection every shift. They were also instructed to empty the left drainage and record the amount. The physician's orders did not include the need to perform any treatment to the nephrostomy tube site that was noted on the After Visit Summary from the hospital at the time of his admission. A review of Resident #82's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She had a functional limitation in her range of motion to bilateral upper extremities. A review of Resident #82's care plans revealed he had a care plan in place for being prone to alterations in her bowel and bladder function related to acute on chronic health conditions, impaired strength & endurance, weakness, unsteadiness on feet, recent UTI, influenza, acute kidney injury on chronic kidney disease- stage 5, and constipation. She was identified on the care plan as having a left sided nephrostomy tube. The interventions only included the need to empty the left nephrostomy tube, record the amount as ordered, and monitor the left nephrostomy for signs and symptoms of infection as ordered. The care plan did not include the need to perform any treatment to the left nephrostomy tube site as was included on the After Visit Summary from the hospital. A review of Resident #82's treatment administration record (TAR's) for February 2024 revealed the nurses were to document the emptying of the left drainage bag and record the amount drained. 11 out of the 44 times in which the nurse should have documented the emptying of the left drainage bag and record the amount, the nurses failed to initial the box or record the amount that had been drained. The nurses were also to initial the TAR every shift to show they were monitoring the left nephrostomy for signs and symptoms of infection. Eight out of 42 times, there were no nurse's initials to show evidence of the nurse assessing the resident's left nephrostomy for signs and symptoms of infection. The TAR also did not provide any documented evidence of the resident's nephrostomy tube site being washed with soap and water every day or that a dressing change had been done to the nephrostomy site every three days as per her hospital discharge instructions. On 02/26/24 at 4:27 P.M., an interview with Resident #82 revealed she had a nephrostomy tube that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 20 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the dressing had only been changed once since her admission. She thought it was to be changed ever couple of days. She denied that anyone had been washing around the nephrostomy site with soap and water as was instructed in her hospital discharge orders. On 02/27/24 at 11:46 A.M., an interview with Licensed Practical Nurse (LPN) #16 revealed she was familiar with Resident #82 and took care of Resident #82 when she still resided in the facility. She indicated she had not worked at the facility long, but recalled the resident had a nephrostomy tube. She was questioned on what the nurses had to do in regards to the care of the resident's nephrostomy tube. She stated they just drained the resident's nephrostomy tube and observed the site for signs and symptoms of infection. She was not aware of there being any treatment order for the care of the nephrostomy tube site. She denied the resident had a dressing to her nephrostomy tube site. She recalled when the resident first came they started cleaning it, but after that they did not. She worked last week with the resident on Monday, Wednesday, and Saturday and denied she did any type of treatment to the resident's nephrostomy tube site and only observed it. On 02/27/24 at 11:48 A.M., an interview with Registered Nurse (RN) #112 revealed the nurses should clean Resident #82's nephrostomy site with normal saline, pat it dry, and place a gauze on it once a day, but would have to check her physician's orders to be sure. They would also drain the nephrostomy tube's bag once a shift and as needed (prn). She was informed the resident's physician's orders did not include any treatment orders pertaining to the cleansing of the nephrostomy tube site or the application of a dressing as was indicated on the resident's hospital discharge orders. She was also informed the resident confirmed in her interview on Monday that she had only had her dressing changed once while in the facility and did not think it was being changed twice a week as it should have been according to what the hospital had told her. She further acknowledged the TAR for February 2024 revealed the nurses were not always documenting the emptying of the nephrostomy bag, recording the output, or that the nephrostomy site was being monitored for signs and symptoms of infection on a consistent basis. The facility denied that they had a policy specific to the care of nephrostomy tubes. The Administrator reported they just followed standards of practice. 2. Review of the medical record for Resident #22 revealed an admission date of 10/23/23 with diagnoses including protein-calorie malnutrition, retention of urine, dementia, type two diabetes mellitus, adult failure to thrive, systemic lupus, depression, metabolic encephalopathy, dysphagia, and cognitive communication deficit. Review of Resident #22's plan of care dated 11/16/23 revealed she had an indwelling foley catheter. Interventions included changing catheter as ordered, changing urinary drainage bag as ordered, emptying catheter bag as ordered, catheter to straight drain as ordered, foley leg strap to secure tubing, monitor skin at strip location, monitory urinary output every shift, monitor for signs of infection, urinary drainage bag to have cover, and monitor for pain discomfort to catheter. Review of Resident #22's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had impaired cognition and had an indwelling catheter. Review of Resident #22's census revealed she returned from the hospital on [DATE] and remained in the facility through 02/26/24. Review of Resident #22's physician order dated 11/06/23 to 02/06/24 revealed an order to empty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 21 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0690 indwelling catheter bag every eight hours for maintenance and this order was restarted on 02/26/24. Level of Harm - Minimal harm or potential for actual harm Review of Resident #22's physician order dated 11/06/23 to 02/06/24 revealed an order for 18 French Scale (fr) and 10 milliliter (ml) balloon to be changed every month and as needed. On 02/26/24 an order was added for 16 Fr and 10 ml balloon to be changed every month and as needed for maintenance. Residents Affected - Few Review of Resident #22's physician order dated 11/07/23 to 02/06/24 revealed an order for foley catheter to straight drain and check every shift and this order was restarted on 02/26/24. Review of Resident #22's physician orders dated 02/08/24 revealed an order for to document output from foley catheter every shift. Review of Resident #22's Medication Administration Record (MAR) for February 2024 revealed from 02/08/24 to 02/25/24 output from the foley catheter was the only care documented related to the catheter. Interview on 02/29/24 at 2:19 P.M. with Unit Manager (UM) #95 revealed Resident #22 had a foley catheter during her entire stay in the facility. UM #95 verified the catheter orders were not restarted until 02/26/24. Resident #22 went without orders for a catheter or catheter care from 02/07/24 to 02/25/24. Based on record review, interviews, and observations, the facility failed to timely order and initiate treatment for urinary tract infections (UTI's) for Resident #63 and failed to timely order and initiate appropriate treatments for Residents #22's catheter and Resident #82's nephrostomy tube. This affected three residents (Resident #22, #63, and #82) of three residents reviewed for catheter and urinary tract infections. The facility census was 93. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of 01/26/2024 with diagnoses that included urinary tract infection, acute kidney failure, presence of urogenital implants (control urine leakage). Review of the most recent Medicare 5 day Minimum Data set (MDS) 3.0 assessment completed on 02/01/24 revealed Resident #63 was cognitively intact, has an indwelling catheter and was frequently incontinent. Review of Resident #63's undated document supplied from OhioHealth Urology Physicians revealed peri-urethral estrogen cream was used for recurrent UTI's and can decrease the risk for UTI's. Review of OhioHealth Urology Physicians order with a date written of 02/15/24 at 4:04 P.M. revealed resident #63 was ordered estradiol (Estrace) vaginal cream with a start date of 02/15/24. An undated document supplied from OhioHealth Urology Physicians revealed peri-urethral estrogen cream was used for recurrent UTI's and can decrease the risk for UTI's. Review of a facility order audit report dated 03/04/24 revealed Resident #63's Estrace vaginal cream order creation date was on 02/27/24 at 3:47 P.M. by Licensed Practial Nurse (LPN) #82. The order supply summary revealed the pharmacy had a supply of the cream with a dispense date of 02/28/24. Review of the Medication Administration Record (MAR) revealed Resident #63 received her first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 22 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0690 administration of Estrace Vaginal Cream on 02/27/24. Level of Harm - Minimal harm or potential for actual harm Interview on 02/26/24 at 2:47 P.M. and on 02/28/24 at 2:38 P.M with Resident #63 stated she had reminded staff to order Estrace vaginal cream every day since her urology appointment because she had been experiencing burning and itching. Residents Affected - Few Interview on 02/27/24 at 03:14 P.M. with LPN #82 verified Resident #63 had a paper prescription dated 02/15/24 for Estrace vaginal cream in the resident's binder. LPN #82 confirmed the paper prescription had not been sent in and was not documented in the electronic medical record. LPN #82 confirmed she submitted the request for the pharmacy to refill during this interview on 02/27/24. Interview on 03/04/24 at 11:37 A.M. with Unit Manager (UM) #95 stated the facility did not receive a paper copy of Resident #63 prescription for Estrace vaginal cream until 02/19/24. UM #95 confirmed the prescription was sent into the pharmacy on 02/27/24 and Resident #63 received her first dose on 02/27/23 at 10:57 P.M. UM #95 confirmed prescriptions are expected to be sent and administered in a timely manner. Interview on 03/04/24 at 7:55 A.M. with the Administrator confirmed medications should be sent into the pharmacy the same day they are received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 23 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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, record review, and policy review, the facility failed to develop and implement a comprehensive, effective and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as ordered, and/or to recognize and address significant/severe resident weight loss. This affected four residents (#19, #22, #23, and #59) of seven residents reviewed for nutrition. The facility census was 93. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/23/23 with diagnoses including protein-calorie malnutrition, encephalopathy, retention of urine, dementia, type two diabetes mellitus, adult failure to thrive, systemic lupus, depression, dysphagia, and cognitive communication deficit. Review of Resident #22's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 11/12/23, revealed the resident had moderately impaired cognition. The MDS reflected Resident #22 weighed 180 pounds and had no significant weight changes. The assessment also noted the resident required substantial or maximal assistance with eating. Review of Resident #22's plan of care, initiated on 11/17/23 (and last revised on 02/16/24), revealed Resident #22 had a potential nutritional problem related to diagnoses, pressure ulcers, history of refusing supplements, and significant weight loss. Interventions included administering medications as ordered, monitoring for signs of dysphagia, monitoring for signs of malnutrition, monitoring lab work, providing diet as ordered, dietitian to evaluate and make changes as needed, and weighing per policy. Review of the plan of care revealed it did not address Resident #22's need for assistance with eating. Review of Resident #22's weights revealed all weights before 12/04/23 were crossed out as incorrect documentation. Resident #22 was documented to weigh between 180 pounds to 180.5 pounds between 11/07/23 and 11/10/23. Resident #22 weighed 140.8 pounds on 12/04/23, Resident #22 weighed 138.8 pounds on 12/07/23, and Resident #22 weighed 139.4 pounds on 12/11/23. Review of Resident #22's progress note, dated 12/11/23, revealed Resident #22 weighed 138.8 pounds which was a significant weight loss over one month. Resident #22 often refused to eat or ate around 25% of her meal. The family had declined hospice. The resident was receiving Mirtazapine (medication used to stimulate appetite) and her diet had recently been upgraded to thin liquids. The dietitian recommended starting Ensure (nutritional supplement) eight ounces three times a day between meals to provide extra calories. Review of Resident #22's physician order, dated 12/11/23 to 12/28/23, revealed she was to receive Ensure three times a day between meals. Review of Resident #22's progress note, dated 12/22/23, revealed the resident was receiving Ensure three times a day but had poor intake of the supplement and the daughter reported Resident #22 did not like it. The resident's daughter additionally stated she did not feel the facility's initial weight of 180 pounds was accurate, as it had been some time since her mother weighed 180 pounds. Due to the residents' limited intake, the dietitian recommended stopping Ensure and beginning Magic Cup (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 24 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 (nutritional supplement) twice a day and four ounces of Mighty Shake (nutritional supplement) three times a day in between meals. Review of Resident #22's weights revealed Resident #22 weighed 138.8 pounds on 12/25/23. Review of Resident #22's physician order, dated 12/28/23, revealed she was to receive Magic Cup twice a day. Review of Resident #22's physician order, dated 12/28/23 through 02/06/24, revealed Resident #22 was to receive Mighty Shake three times a day between meals. Review of Resident #22's progress note, dated 12/29/23, revealed the Magic Cup was unavailable. Review of the Medication Administration Record (MAR) for December 2023 revealed Magic Cup was marked see note on 12/29/23 at 7:30 A.M. There was no administration information for Mighty Shake. Review of Resident #22's weights revealed Resident #22 weighed 131 pounds on 01/02/24 which was a severe weight loss of 6.9% from 12/04/23 when she weighed 140.8 pounds. She weighed 119 pounds on 01/20/24, she weighed 118.6 pounds on 01/22/24, and she weighed 124.0 pounds on 01/24/24 which was a severe weight loss of 10.6% from 12/25/23 when she weighed 138.8 pounds. Resident #22 weighed 128.2 pounds on 02/07/24 and weighed 124.5 pounds on 02/09/24. Review of Resident #22's physician order dated 02/08/24 revealed she was on a regular diet. Review of Resident #22's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #22 had impaired cognition. Resident #22 weighed 124 pounds and had lost weight outside a prescribed regimen. The resident's weight was documented to be 123.6 pounds on 02/12/24. Review of Resident #22's weights revealed she weighed 122.5 pounds on 02/19/24, and weighed 121.6 pounds on 02/26/24 which was a severe weight loss of 13.6% over 90 days, since her weight of 140.8 pounds on 12/04/23. Resident #22 was five feet and nine inches tall, and her height and body weight as of 02/26/24 indicated a body mass index (BMI) of 18 which classified her as underweight. Review of Resident #22's physician order dated 11/06/23 to 02/06/24 revealed an order for Mirtazapine 15 milligrams (mg) one tablet by mouth at bedtime for depression. This was started again on 02/07/24 and indicated it was for poor appetite. Review of Resident #22's meal intake from 01/31/24 to 02/28/23 revealed Resident #22 consumed 0 to 25% of her meal on 13 occasions, she consumed 26 to 50% on 20 occasions, she consumed 51-75% on 17 occasions, and she consumed 76-100% on three occasions. Resident #22 refused one meal. Review of Resident #22's MAR for January 2024 revealed the Magic Cup had no administration documentation for 01/10/24. It was indicated to see note for the morning administration on 01/15/24, 01/25/24, 01/26/24, and 01/29/24. Review of the documentation for the Mighty shake revealed it was indicated to see note for the 8:00 A.M. administration on 01/02/24, 01/04/24, and 01/25/24, and for the 2:00 P.M. administration on 01/04/24 and 01/05/24. On 01/10/24, there was no Mighty Shake administration documentation for the 8:00 A.M. or 2:00 P.M. administration. Review of Resident #22's progress notes from 01/01/24 to 01/31/24 revealed on 01/04/24, the 8:00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 25 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 A.M. Mighty Shake was not available, and there was no explanation for the missing 2:00 P.M. Mighty Shake administration. On 01/05/24, there was no explanation for the missing Mighty Shake administration. Review of the progress notes dated 01/10/24 revealed no documentation related to the Magic Cup or Mighty Shake. Review of the progress notes dated 01/15/24 and 01/25/24 revealed the Magic Cup was not available on 01/15/24 and 01/25/24, and the Mighty Shake was unavailable on 01/25/24. There was no documented reason for not administering the Magic Cup on 01/26/24 or 01/29/24. Review of Resident #22's MAR dated 02/01/24 to 02/23/24 revealed it was indicated to see note for the 7:30 A.M. Magic Cup administration on 02/01/24, 02/12/24, 02/16/24, 02/19/24, and 02/22/24, as well as the 4:00 P.M. Magic Cup administration on 02/08/24, 02/12/24, and 02/23/24. Review of Resident #22's progress notes, dated 02/01/24 to 02/25/24, revealed on 02/01/24, 02/08/24, and 02/16/24, the Magic Cup was documented as unavailable. Review of the progress note, dated 02/12/24, revealed for the first administration of Magic Cup, the Magic Cup was not received and for the second administration of Magic Cup, the kitchen was contacted. Review of the progress notes dated 02/19/24, 02/22/24, and 02/23/24 revealed there was no indication why Resident #22's Magic Cup was not administered. Resident #22 was sent to the hospital on [DATE] and returned from the hospital on [DATE]. The resident was hospitalized for treatment of a urinary tract infection. Review of Resident #22's nutritional assessment, dated 02/16/24, revealed Resident #22 was 69 inches tall and 123.6 pounds, and had a BMI of 18.3 which classified her as underweight. Resident #22 had a 5.7% weight loss over one month. Resident #22's food intake was between 26% and 50%, and she was receiving Magic Cup twice a day. There was no description of Resident #22's intake of her nutritional supplements. Resident #22 required assistance with eating. Resident #22 had a pressure ulcer. The dietitian recommended eight ounces of Ensure three times a day to help provide additional calories. Interview on 02/28/24 at 12:16 P.M. with Resident #22's daughter revealed Resident #22 needed to be fed at meals and she did not feel the facility was doing this consistently. Observation on 12/29/24 at 12:58 P.M. revealed Resident #22 was in her room and was a family member was assisting her with her lunch. Interview on 03/04/24 at 10:56 A.M. with Dietitian #69 verified Resident #22 had not received her nutritional supplements as ordered. She reported if the kitchen had not sent a supplement then she would expect nursing to call the kitchen and clarify. Dietitian #69 verified Resident #22 had a significant weight loss in January 2024 that had not been addressed. Dietitian #69 reported she was not notified by nursing staff when the significant weight loss occurred, and she ran her own reports weekly but must have missed it. She was unsure why the Mighty Shake had not been resumed upon her readmission in February 2024. Dietitian #69 additionally verified she had recommended Ensure on 02/16/24 and it had not been initiated. Dietitian #69 was not present in December 2023 and had been unaware that Ensure had been tried with Resident #22 before and was refused by Resident #22. Dietitian #69 was unsure if switching appetite stimulants or tube feeding had been discussed. Interview on 03/04/24 at 11:13 A.M. with Unit Manager #95 verified the nurses had not been administering supplements to Resident #22 as ordered. She reported when supplements from the kitchen were unavailable, she would expect them to be offering other supplements. However, she verified the medical record did not indicate this was happening. She believed tube feeding for Resident #22 had been refused in the hospital. Unit Manager #95 reported Resident #22 was very particular and only ate when her daughter was there to feed her. Unit Manager #95 reported Resident #22's daughter came in at most (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 26 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 meals to assist her. Level of Harm - Minimal harm or potential for actual harm Review of the policy titled Residents at Nutritional Risk, dated 09/07/22, revealed if a resident had experienced a weight variance of greater than or equal to five pounds, they were to be reweighed within 24 hours. If the weight change was deemed to be accurate the dietitian was to be notified immediately and the dietitian was to follow up within 48 hours of nursing notification. Residents Affected - Few 2. Review of the medical record for Resident #19 revealed an admission date of 01/16/19 with diagnoses including encephalopathy, type two diabetes mellitus, dysphagia, dementia, depression, osteoporosis, heart failure, and repeated falls. Review of Resident #19's physician order, dated 11/22/23, revealed the resident was to receive a regular diet with nectar consistency liquids. Review of the plan of care, dated 12/14/23, revealed Resident #19 had a potential for nutritional risk related to overweight status, need for finger foods, family noncompliance with straws, diagnoses, significant weight loss, variable intake, and advanced age. Resident #19 was to get finger foods due to choking and meal assistance. Interventions included controlling any pain or nausea before meals, encouraging intake of more than 75%, encouraging the resident to be out of bed during meals, family to provide favorite foods for resident to consume, monitoring for changes in nutritional status, monitoring for signs of chewing or swallowing difficulty, monitoring for signs of dehydration, monitoring intake at meals, providing diet as ordered, and staff to supervise and cue during meals. Review of Resident #19's quarterly MDS 3.0 assessment dated [DATE] revealed she had impaired cognition. She had not had any significant weight changes. Review of Resident #19's physician order dated 11/08/23 to 02/19/24 revealed an order to receive Nutritional Juice eight ounces twice a day to be provided by the kitchen. This order was revised on 02/20/24 and continued to include the amount consumed in the Medication Administration Record. Review of Resident #19's Medication Administration Record from 02/01/24 to 02/26/24 revealed the nutritional juice (nutritional supplement) was not administered and indicated to see note for the first administration on 02/02/24, 02/03/24, 02/08/24, 02/09/24, 02/12/24, 02/15/24, 02/16/23, 02/19/24, 02/22/24, 02/23/24, and 02/26/24. It was not administered and indicated to see note for the second administration on 02/01/24, 02/02/24, 02/08/24, 02/09/24, 02/12/24, 02/16/24, 02/22/24, 02/23/24, and 02/26/24. Review of Resident #19's progress notes revealed there was no explanation for why the nutritional juice was not given on 02/01/24, 02/02/24, 02/03/24, 02/19/24, 02/22/24, 02/23/24, and 02/26/24. On 02/08/24, 02/09/24 and 02/12/24 it was indicated the nutritional juice was unavailable or not received. On 02/15/24 it was indicated she consumed none of the drink. On 02/16/24 for the first administration it was indicated a fax was sent and there was no note indicating why the second administration was missed. Observation on 02/29/24 at 12:30 P.M. of lunch pass revealed Resident #19 had not been given a tray. Interview at that time with Unit Manager #95 revealed she did not receive her lunch or any items from the facilities kitchen because she received a Kosher meal from the assisted living. Observation of Resident #19 revealed she had received her meal but had not received any supplement. Unit Manager #95 verified the observation, she was unsure how long Resident #19 had been receiving meals from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 27 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 the assisted living. Level of Harm - Minimal harm or potential for actual harm Interview on 02/29/24 at 12:32 P.M. with Registered Nurse (RN) #120 revealed she expected the assisted living to send the supplement with meals. Residents Affected - Few Interview on 03/04/24 at 10:56 A.M. with Dietitian #69 verified Resident #19 had not received her supplements as ordered. She reported if the kitchen had not sent a supplement, she would expect nursing to call the kitchen and clarify. 3. Review of the medical record for Resident #23 revealed an admission date of 01/11/22 with diagnoses including cognitive communication deficit, dysphagia, hypertension, anorexia, and adult failure to thrive. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 had severely impaired cognition. She weighed 108 pounds with no significant changes and was on a mechanically altered diet. Review of Resident #23's plan of care, dated 02/20/24, revealed Resident #23 was at nutritional risk related to pureed diet, requiring feeding assistance, being legally blind, edentulous, diagnoses, variable intake and advanced age. Interventions included administering medications as ordered, encouraging intake of more than 75% of meals, monitoring for signs of dehydration and malnutrition, offering fluids of choice, providing supplements as ordered, providing diet as ordered and weighing as ordered. Review of Resident #23's physician order dated 04/06/23 revealed Magic Cup was to be given two times a day for supplement. It was updated on 02/26/24 to indicate Mighty Shake could be given instead. Review of Resident #23's MAR for February 2024 revealed the Magic Cup was not received and was marked as see note for the first administration on 02/08/24, 02/09/24, 02/12/24, and 02/16/24 and for the second administration on 02/08/24, 02/09/24, 02/12/24 and 02/23/24. Review of Resident #23's progress notes from 02/01/24 to 02/23/24 revealed it was indicated the supplement was unavailable for both administrations on 02/08/24 and 02/09/24. For the first administration on 02/12/24 it was indicated the supplement was not received and for the second administration there was no reason given. On 02/16/24 and 02/23/24 there was no note to indicate why Magic Cup was not given. Interview on 03/04/24 at 10:56 A.M. with Dietitian #69 verified Resident #23 had not received her supplement as ordered. She reported if the kitchen had not sent a supplement, she would expect nursing to call the kitchen and clarify. 4. Review of the medical record for Resident #59 revealed an admission date of 09/07/20 with diagnoses including tracheostomy status, gastrostomy status, diabetes, and malignant neoplasm at the base of the tongue. Further review of Resident #59's medical record revealed the resident was receiving chemotherapy. Review of Resident #59's care plan, dated 04/19/23, revealed the resident was at nutritional risk related to requiring pureed texture, malignant neoplasm of base of tongue, tracheostomy status, dry mouth, Vitamin D deficiency, anxiety disorder, unspecified cataract, hypotension, gastrostomy status, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 28 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 insomnia, unspecified mood disorder, unspecified conduct disorder, dysphagia. unspecified severe protein-calorie malnutrition, neoplasm-related pain, anorexia, variable intake, altered nutrition needs related to diabetes, and advanced age. Interventions included administer medications as ordered per Percutaneous Endoscopic Gastrostomy tube (feeding tube), monitor/record/report to Medical Director as needed signs and symptoms of significant weight loss which included three pounds in one week, more than five percent in one month, greater than 7.5 percent in three months, and greater than 10 percent in six months, the registered dietitian to evaluate and make flush recommendations as needed, and to weigh per facility policy. Review of Resident #59's quarterly MDS assessment, dated 12/15/23, revealed Resident #59 was cognitively intact and had a gastrostomy tube. Review of Resident #59's weights revealed Resident #59 weighed 162 pounds on 12/26/23, weighed 155 pounds on 01/02/24, and weighed 144.8 pounds on 02/01/24. The weight records indicated Resident #59 experienced non-significant weight loss of 4.3 percent from 12/26/23 to 01/02/24 and a severe 10.62 percent weight loss from 12/16/23 to 02/01/24. There were no additional weights obtained for Resident #59 between 12/26/23 and 02/27/24. Review of Resident #59's physician orders revealed the facility had not addressed the weight loss until 02/27/24 when Resident #59's orders were changed from Jevity (liquid nutrition) 1.2 give 237 milliliters (ml) bolus seven times daily for nutrition to provide 1995 calories to Jevity 1.5 one carton (237 ml) six times per day. The orders were written to be administered through Resident #59's gastrostomy tube. Review of Resident #59's progress notes revealed Resident #59's severe weight loss of 10.62 percent from 12/16/23 to 02/01/24 was not addressed until 02/27/24 when his tube feeding order was changed. Interview on 02/27/24 at 9:51 A.M. with Resident #59 revealed he does all of his own gastrostomy tube feeding and he had recently lost weight. Interview on 02/28/24 at 2:47 P.M. with Dietitian #69 revealed she works in the facility five days a week and runs reports that show significant weight losses. She continued that Resident #59 had a significant weight loss on 02/01/24 when he went from 162 pounds on 12/26/23 to 144.8 pounds on 02/01/24. She revealed he was at a high risk for weight loss due to the fact he does his own gastrostomy tube feedings and is in chemotherapy. She stated she missed the significant weight loss on 02/01/24 and it was not discovered until 02/27/24. She reported it was her responsibly to run the reports, identify the weight loss, contact nursing and the physician, and determine what interventions to put in place. She confirmed this did not happen timely due to missing the weight loss on her report at the beginning of February 2024. Review of the facility policy titled Resident Weight, dated 10/31/21, revealed the policy recommended that residents with tube feedings be weighed weekly unless otherwise indicated in the care plan or by physician order. Under the reporting weights section, weight loss will be discussed at a weekly clinical meeting. Review of the facility policy titled Residents at Nutritional Risk, dated 09/07/22, revealed a resident who had experienced a significant weight loss or gain of five percent in one month 7.5 percent in three months or 10 percent in six months is considered a high nutritional risk. Residents who are identified at nutritional risk will be included in a report to be updated by the Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 29 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 Dietitian Nutritionist (RDN) and reviewed by the interdisciplinary team weekly. For addressing weight concerns the facility RDN follows up within 48 hours of nursing notification with a progress note in the resident's medical record detailing the nutritional risk identified and nutritional intervention recommendations as appropriate. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00151376. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 30 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure Resident #59 was capable of completing his own tracheostomy care and that tracheostomy care was completed as ordered. This affected one resident (Resident #59) out of one resident reviewed for tracheostomy care. Residents Affected - Few Findings include: Review of the medical record for Resident #59 revealed an admission date of 09/07/20. Diagnosis included tracheostomy status, gastrostomy status, diabetes, and malignant neoplasm at the base of the tongue. Review of Resident #59's quarterly MDS assessment revealed the resident was cognitively intact and had a tracheostomy. Review of Resident #58's medical record revealed no evidence Resident #59 was assessed and determined to be competent to complete his own tracheostomy care. Review of Resident #59's February 2023 physician orders revealed an order to remove stoma vent twice daily to clean, and an order to suction the resident's stoma and keep clean of dried secretions as needed. The facility nurses were signing the order indicating they were removing the stoma vent twice daily to clean. The orders did not indicate the resident was able to provide his own tracheostomy care. Review of Resident #59's care plans dated prior to 02/27/24 revealed the resident did not have a care plan indicating he does his own tracheostomy care. Observation 02/27/24 at 09:51 A.M of Resident #59 revealed he had a tracheostomy. His room had various tracheostomy supplies present. Interview on 02/27/24 at 09:51 A.M. Resident #59 revealed he does all his own tracheostomy care and has done so since his admission to the facility. Interview on 02/28/24 at 11:59 A.M. Unit Director #95 revealed Resident #59 has always done his own tracheostomy care since his admission to the facility. She confirmed there was no evidence the facility assessed his capabilities to perform his own tracheostomy care. She also confirmed he did not have an order to do his own care and his care plan did not reflect the resident did his own tracheostomy care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 31 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure their contracted pharmacy provided pharmaceutical services to ensure medications were available for administration as ordered by the physician. This affected one resident (Resident #85) of two residents reviewed for antibiotic use. The facility census was 93. Findings include: A review of Resident #85's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a peritoneal abscess, post-procedural complications and disorders of the digestive system, bariatric surgery status, peritoneal adhesions (post-procedural and post-infection), and perforation of the bile duct. A review of Resident #85's physician's orders revealed she had an order to receive Zosyn 4.5 Grams (Gm) intravenously (IV) every eight hours for a peritoneal abscess. The order had been in place since the resident's admission into the facility. A review of Resident #85's medication administration record (MAR) for February 2024 revealed the the nurses added a 9 to the box for doses of the IV Zosyn that was to be given to the resident on 02/12/24 at 2:00 P.M. and 02/12/24 at 10:00 P.M. The legend on the MAR indicated a 9 meant other/ see progress notes. A review of Resident #85's progress notes revealed a nurse's note dated 02/12/24 at 2:09 P.M. that indicated the resident's IV Zosyn was not administered at that time due to the medication not being available from their pharmacy. The note indicated the nurse had contacted the pharmacy and the IV Zosyn was to be delivered at 6:00 P.M. during the pharmacy delivery run. Further review of Resident #85's progress note revealed a nurse's note dated 02/23/24 at 12:11 A.M. that indicated the resident's IV Zosyn was again not administered due to its unavailability. The nurse's note indicated they were still awaiting delivery of the IV antibiotic from their pharmacy. Findings were verified by the Director of Nursing (DON). On 02/29/24 at 9:46 A.M., an interview with the DON confirmed two of the doses of Resident #85's IV Zosyn had not been administered to the resident when scheduled due to it not being available from their pharmacy for administration. He denied they had IV Zosyn on hand in their contingency supply that could have been pulled for administration when the IV Zosyn was documented as not having been available. He acknowledged the resident had been on IV Zosyn since his admission to the facility on [DATE] and should have been made available for administration by their contracted pharmacy. On 02/29/24 at 10:30 A.M., an interview with Resident #85 confirmed there were a couple of times she was not given her IV Zosyn as ordered when the medication was not available for administration from the pharmacy. She only recalled one other time when she did not get it, but that was due to her being out of the facility for an appointment. She returned from her appointment too late and it was too close to her next scheduled dose for her to be given the dose of the antibiotic that had been missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 32 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, review of drug manufacturer's instructions, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5 percent (%). The facility had two medication errors out of 35 opportunities resulting in a medication error rate of 5.71%. This affected two residents (#248 and #397) of four residents reviewed for medication administration. The facility census was 93. Residents Affected - Few Findings include: 1. Review of Resident # 248's medical record revealed an admission date of 12/29/2023. Diagnoses included osteomyelitis of the vertebra (sacral and sacrococcygeal region), aphasia following a cerebral infarction, unspecified severe protein-calorie malnutrition, and Parkinson's disease. Review of Resident #249's February 2024 physician orders revealed an order for Ceftazidime Intravenous (IV) Solution (antibiotic) Reconstituted 2 grams with instructions to use two grams intravenously three times a day related to osteomyelitis of the vertebra. The order was scheduled to be completed at 6:00 A.M., 2:00 P.M., and 10:00 P.M. Interview on 02/26/24 at 10:49 A.M. Family Member #304 revealed Resident #59's IV antibiotic was not always done timely and was frequently given late. Observation on 02/28/24 P.M. at 3:34 P.M revealed The Director of Nursing (DON) entered the resident's room and began the process of administering Resident #59's Ceftazidime IV antibiotic. Interview on 02/29/24 at 11:10 A.M. the DON confirmed the facility had an hour before and after the scheduled time to administer medications. He confirmed Resident #59's Ceftazidime IV antibiotic was scheduled for 2:00 P.M. and was not initiated until 3:34 P.M. 2. Review of Resident #397's medical record revealed an admission date of 02/27/23. Diagnoses included type two diabetes mellitus, anxiety, asthma, and unspecified disorder of eye and adnexa. Review of Resident #397's orders revealed the following order with a start date of 02/28/24 at 8:00 A.M. for prednisolone Acetate Opthalmic Suspension 1% (Prednisolone Acetate) instill 1 drop in both eyes one time a day. Review of the Medication Administration Record (MAR) for Resident #397 revealed she was to receive Prednisolone Acetate eye drops on 02/28/24 for scheduled 8:00 A.M. dose. Observation on 02/28/24 at 8:59 A.M. revealed Licensed Practical Nurse (LPN) #52 administer to Resident #397 Prednisolone Acetate eye drops into the sclera of bilateral eyes. Interview on 02/28/24 at 9:59 A.M. with LPN #52 verified the eye drops were administered into the residents sclera and LPN #52 verbalized the medication was to be administered into the conjunctival sac. Interview on 02/28/24 at 9:30 A.M. with Unit Director #28 confirmed staff are expected to place eye drops into residents conjunctival sac or follow manufacturer's instructions when administering eye drops. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 33 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Record review of Prednisolone Acetate manufacturer's instructions dated April 2020 revealed drops should be instilled into the conjunctival sac. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 34 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on interview, observation, and record review the facility failed to dispose of expired medication for Resident #47. This affected one resident (#47) of four residents reviewed for medication administration. The facility census was 93. Findings include: Review of the medical record for Resident #47 revealed an admission date of 10/05/2023 with diagnoses including end stage renal disease, type two diabetes mellitus with long term use of insulin, and adult failure to thrive. Review of the most recent Minimum Data set (MDS) 3.0 assessment completed on 01/10/24 revealed Resident #47 was cognitively intact and required a hypoglycemic medication to decrease blood sugars. Review of physician orders revealed an order with a start date of 01/05/24 for Lantus Subcutaneous Solution 100 unit/milliliters (Insulin Glargine) for diabetes at bedtime. Review of the Medication Administration Record for February 2024 revealed Resident #47 received his ordered dose of Insulin Glargine on 02/27/24 at 9:00 P.M. and his blood sugars were being monitored appropriately and were controlled within a range of 139 to 193 between 02/27/24 through 02/29/24. Observation on 02/28/24 at 8:30 A.M. with Assistant Director of Nursing (ADON) #78 of the medication cart on the unit YASS 4 revealed an insulin glargine pen in drawer one for Resident #47 with an open date of 01/23/24. ADON #78 confirmed the pen did not have an expiration date and should be disposed of. Interview on 02/28/24 at 5:37 P.M. with Licensed Practical Nurse (LPN) #82 confirmed Resident #47 Insulin Glargine pen should have been disposed of and replaced. LPN #82 confirmed it was the only Insulin Glargine pen in the Medication cart for Resident #47 on 02/28/24. Interview on 02/28/24 between 12:30 P.M. and 1:00 P.M. with the Administrator confirmed manufacturer's instructions to dispose of Insulin Glargine 28 days after opening. Review of Insulin Glargine manufacturers information dated May 2023 revealed a prefilled pen should be disposed of after 28 days from the open date. Review of facility policy titled Storage and Expiration dating of medications dated 08/07/23 states the facility should ensure that food is not to be stored in the refrigerator, freezer, or general storage areas where medications and biologicals are stored. Additionally, the facility should follow manufacturers guidelines for expirations dates for opened medications. Lastly, the facility should ensure the medications for each resident are stored in their original containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 35 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, review of tray tickets, and review of diet descriptions the facility failed to ensure Resident #3 was served a puree diet as ordered. This affected one resident (#3) of nine residents reviewed for food/nutrition. The facility identified nine residents ( #59, #3, #31, #50, #250, #254, #27, #263, #23) ordered a pureed diet. The facility census was 93. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/07/22 with diagnoses including dementia, dysphagia, thrombocytopenia, somnolence, adult failure to thrive, hepatic failure, gastrostomy status, depression, and cognitive communication deficit. Review of Resident #3's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed they were rarely or never understood. She was on a mechanically altered diet. Review of Resident #3's physician order dated 10/30/23 revealed they were to receive a regular diet with dysphagia puree texture and nectar thick liquids. Observation on 02/27/24 at 8:24 A.M. revealed Resident #3's was in her room with her meal tray. State Tested Nursing Aide (STNA) #51 warmed up her plate and returned it to Resident #3's room revealing she was preparing to feed her. STNA #51 indicated each item on Resident #3's tray which included a bowl labeled 'mixed fruit'. Observation revealed whole mandarin oranges were in the bowl. STNA #51 verified the fruit was not pureed. STNA #51 indicated the whole mandarin oranges were soft and could probably be mashed up. Review of the texture-modified diets descriptions, undated, revealed a national dysphagia diet pureed included foods that were easy to swallow because they were blended, whipped, or mashed until they reach a 'pudding-like' texture. Foods on this diet were to be smooth and free of lumps. Fruits that were not recommended included all non-pureed whole fruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 36 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review the facility failed to ensure food allergens were not served to Resident #261, and failed to ensure Resident #1, who had a physician identified lactose intolerance, was not served lactose containing foods. This affected two residents (#261 and #1) of nine residents reviewed for food/nutrition. The facility census was 93. Findings include: 1. Review of the medical record for Resident #261 revealed an admission date of 08/30/22 with a readmission date of 02/23/24, and diagnoses included acute pancreatitis, chronic obstructive pulmonary disease, end stage renal disease and dependent on renal dialysis, chronic heart failure, and osteoporosis. Review of Resident #261's in-progress comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed they had intact cognition. Review of Resident #261's allergy list revealed a mild fish allergy added on 08/30/22. Observation on 02/28/24 at 1:15 P.M. revealed State Tested Nursing Assistant (STNA) #114 delivering meal trays. She grabbed Resident #261's tray off the cart and entered her room. Resident #261 asked what the meal was and STNA #114 reported it was fish. Resident #261 reported she was allergic to fish so STNA #114 removed the meal from her room and did not serve the meal to her. Interview on 02/28/24 at 1:15 P.M. with [NAME] President of Operations #66 and Culinary Operations Support #67 verified Resident #261 should not have received fish on her meal tray. 2. Review of the medical record for Resident #1 revealed an admission date of 10/06/20 with diagnoses including anxiety disorder, dysphagia, anorexia, adjustment disorder, alcohol dependence, heart failure, cognitive communication deficit, and dementia. Review of Resident #1's comprehensive MDS 3.0 assessment dated [DATE] revealed they had severely impaired cognition. Review of Resident #1's physician order dated 11/22/22 and revised 12/20/23 revealed Resident #1 was to be on a regular diet with dysphagia advanced texture. The resident was lactose intolerant. Observation on 02/29/24 at 12:50 P.M. revealed Resident #1 was being assisted in the dining room by STNA #91. She was observed to have a carton of milk that did to indicate on the carton it was lactose-free, and a Caprese salad that included mozzarella cheese ( a lactose containing cheese). Interview on 02/29/24 at 12:54 P.M. with STNA #91 and Registered Nurse (RN) #120 verified Resident #1 had received a carton of milk that was not specified as lactose-free and mozzarella cheese. RN #120 additionally verified that her medical record indicated she was lactose intolerant. Review of Resident #1's tray ticket revealed the only food allergy listed was strawberries. Resident #1 was to receive milk and the Caprese salad. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 37 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, medical record review, and policy review the facility failed to provide thickened liquids as ordered for one resident (#19). This affected one resident (#19) of nine residents reviewed for food/nutrition. The facility identified six residents (#3, #50, #19, #55, #263 and #42) who required thickened liquids. The facility census was 93. Findings include: Review of the medical record for Resident #19 revealed an admission date of 01/16/19 with diagnoses including encephalopathy, type two diabetes mellitus, dysphagia, dementia, depression, osteoporosis, heart failure, and repeated falls. Review of Resident #19's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. She was on a mechanically altered diet. Review of Resident #19's physician order dated 11/22/23 revealed she was to receive nectar consistency liquids. Observation on 02/29/24 at 12:37 P.M. revealed Resident #19 in her room with her meal. She was noted to have a cup of juice at normal, unthickened consistency. Interview on 02/29/24 at 12:37 P.M. with Speech Language Pathologist (SLP) #125 verified the juice was not thickened and Resident #19 required thickened liquids. Observation on 03/04/24 at 8:10 A.M. revealed Resident #19 in her room with her meal. On her tray was a carton of milk, water, and orange juice which were not nectar thick consistency. Interview on 03/04/24 at 8:13 A.M. with State Tested Nursing Assistant (STNA) #91 verified the liquids on Resident #19's were not thickened liquids. STNA #91 did not think Resident #19 required thickened liquids. Interview on 03/04/24 at 8:22 A.M. with Registered Nurse (RN) #120 verified Resident #19 required nectar thick liquids, and she would request new liquids from the kitchen. Interview on 03/04/24 at 11:13 A.M. with Unit Manager #95 revealed the facility procedure was for the kitchen to send thin liquids to the resident and nursing staff were supposed to thicken them. Review of the facility policy Thickened liquids dated 09/07/22, revealed nectar thick liquids were equivalent to mildly thick liquids. According to the policy nursing's role was to serve commercial pre-thickened liquids at mealtimes and those that were not commercially thickened would need prepared for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 38 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview the facility failed to ensure the kitchen's hood filters were free from grease and dust. This had the potential to affect all 91 residents who consumed food from the kitchen. The facility identified two residents (#46 and #48) who ate nothing by mouth. The facility census was 93. Findings include: Observation on 02/26/24 at 8:55 A.M. of the kitchen revealed the filters in the hood which was over the stove tops where food was cooked had a thick build up of grease and dust. Interview on 02/26/24 at 8:55 A.M. with Dietary Manager (DM) #70 verified the observation. DM #70 reported maintenance was responsible for cleaning the hood and he believed they did it twice a year. Interview on 02/28/24 at 1:26 P.M. with [NAME] President of Operations #66 and Culinary Operations Support #67 reported maintenance cleaned the hoods twice a year. Interview on 02/28/24 at 1:55 P.M. with Maintenance Director #130 revealed the hood received maintenance twice a year, however, the kitchen should have been cleaning the filters in between. He reported based on what he understood the kitchen should clean the hood vents every three months. This deficiency represents noncompliance identified during the investigation of complaint OH00151122. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 39 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure resident records were complete and accurate regarding medications received and the proper location of wounds. This affected three residents (Resident #30, #46, and #85) of 25 residents reviewed for complete and accurate records. The facility census was 93. Findings include: 1. A review of Resident #85's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a peritoneal abscess, post-procedural complications and disorders of the digestive system, bariatric surgery status, peritoneal adhesions (post-procedural and post-infection), and perforation of the bile duct. A review of Resident #85's physician orders revealed she had an order to receive Zosyn 4.5 Grams (Gm) intravenously (IV) every eight hours for a peritoneal abscess. The order had been in place since the resident's admission into the facility. A review of Resident #85's medication administration record (MAR) for February 2024 revealed there were seven times in which the nurses did not document the resident's IV Zosyn had been administered as ordered. The nurses failed to enter their initials to show the antibiotic had been given to the resident on 02/03/24 at 2:00 P.M., 02/04/24 at 2:00 P.M., 02/06/24 at 6:00 A.M., 02/21/24 at 2:00 P.M., 02/22/24 at 2:00 P.M., 02/24/24 at 2:00 P.M., and 02/25/24 at 2:00 P.M. Findings were verified by the Director of Nursing (DON). On 02/29/24 at 9:46 A.M., an interview with the DON confirmed there were seven times a nurse failed to initial the MAR to reflect the IV Zosyn had been administered to Resident #85 as ordered. He acknowledged without the nurses signing off the MAR to show the IV Zosyn had been given it was difficult to show those doses had been provided. He reported the nurses should be signing off the MAR when medications were given. On 02/29/24 at 10:30 A.M., an interview with Resident #85 revealed she felt like she had received her IV Zosyn as ordered with the exception of the two doses in which the medication was not available for administration and a third in which she was out of the facility for an appointment when a dose was due. She denied she had not been given the IV Zosyn the seven times it was not signed off on the MAR. She indicated it was likely that the nurses gave her the IV Zosyn on those days and just failed to document it on the MAR. 3. Review of the medical record for Resident #30 revealed an admission date of 10/31/23 with diagnoses including spinal stenosis, osteoporosis, cord compression, chronic respiratory failure, type two diabetes mellitus, chronic pain syndrome, ankylosing spondylitis of spine, and gout. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition. Review of the plan of care dated 11/13/23 revealed Resident #30 was prone to pain and hurting related to acute on chronic health conditions including spinal stenosis, chronic pain, gout, muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 40 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few spasms, generalized pain, cervical cord compression, and ankylosing spondylitis. Interventions included administering pain medications as ordered, monitoring for signs and symptoms of pain daily, notifying physician of non-relieved pain, offering non-pharmacological interventions as needed for pain management, and pain risk assessment as scheduled. Review of the plan of care dated 11/13/23 revealed Resident #30 was on pain medication therapy related to pain relief. Interventions included administering analgesics as ordered, asking the physician to review medications if side effects persist, monitor for increased risk for falls, and monitoring as needed for adverse reactions. Review of Resident #30's physician orders dated 12/06/23 to 02/22/24 revealed an order for Oxycodone 5 milligrams (mg) every four hours as needed. Review of Resident #30's physician order dated 02/22/24 revealed an order for Oxycodone 15 mg one tablet every four hours as needed for pain. Review of Resident #30's MAR for 02/01/24 to 02/26/24 revealed Oxycodone was given on 02/01/24 five times, on 02/02/24 four times, on 02/03/24 two times, on 02/04/24 two times, on 02/05/25 four times, on 02/06/24 four times, on 02/07/24 three times, on 02/08/24 four times, on 02/09/24 three times, on 02/10/24 two times, on 02/11/24 three times, on 02/12/24 four times, on 02/13/24 four times, on 02/14/24 four times, on 02/15/24 five times, on 02/16/24 six times, on 02/17/24 four times, on 02/18/24 five times, on 02/19/24 four times, on 02/20/24 five times, on 02/21/24 six times, on 02/22/24 four times, on 02/23/24 five times, on 02/24/24 once, on 02/25/24 three times, 02/26/24 five times, and on 02/27/24 three times. Review of Resident #30's controlled substance record for 02/01/24 to 02/26/24 revealed additional Oxycodone administrations outside of what was documented in the MARs. On 02/03/24 Oxycodone was administered five times, on 02/04/24 it was administered six times, on 02/07/24 it was administered five times, on 02/08/24 it was administered five times, on 02/09/24 it was administered five times, on 02/10/24 it was administered five times, on 02/11/24 it was administered six times, on 02/12/24 it was administered five times, on 02/13/24 it was administered six times, on 02/17/24 it was administered five times, on 02/22/24 it was administered five times, on 02/23/24 it was administered six times, on 02/24/24 it was administered five times, on 02/25/24 it was administered five times, and on 02/26/24 it was administered six times. Interview on 02/26/24 at 3:08 P.M. with Resident #30 reported no concerns related to missing pain medication. Interview on 02/28/24 at 9:22 A.M. with Unit Manager (UM) #95 verified Resident #30's MARs did not match the controlled substance record due to inaccurate documentation. UM #95 explained a narcotic count was done for Resident #30's narcotics and no discrepencies were identified. UM #95 added Resident #30, who had been a physician, had been setting his alarm for every four hours so he could make every person in managment aware in the event he had not been receiving his medication when he needed it. 2. Review of the medical record for Resident #46 revealed an admission date of 01/03/2020 with diagnoses including epilepsy, functional quadriplegia, and stenosis of larynx. Review of the most recent Minimum Data set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #46 was severely cognitively impaired and was dependent on two person staff assist for personal care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 41 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0842 Review of additional diagnoses dated 11/14/2023 revealed an abrasion of the left foot. Level of Harm - Minimal harm or potential for actual harm Review of a wound evaluation and management summary from VOHRA (wound physicians) wound solutions on 11/22/23 revealed Resident #46 had a skin tear of the left dorsal foot. Residents Affected - Few Review of orders for February 2024 revealed an order dated 02/07/24 to apply xeroform and cover with gauze island dressing to left foot Review of the facility skin and wound evaluations for Resident #46 dated 12/01/23, 12/07/23, 12/13/23, 12/27/23, 01/03/24, 01/15/24, 01/25/24, 02/02/24, 02/09/24. 02/21/24, 02/29/24 revealed Resident #46 had a category III skin tear to Left Dorsum - 3rd Digit (Toe), Lateral . Observation of Resident #46 on 02/27/24 at 09:26 A.M. with Licensed Practical Nurse (LPN) #82 revealed Resident #46 had a gauze island dressing to her left dorsal foot and not the third digit (toe). LPN #82 confirmed the only wound present on Resident #46 as of 02/27/24 was the left dorsal foot. Interview on 03/04/24 at 11:37 A.M. with Unit Director #95 confirmed Resident #46's wound location was inaccurately documented as Left Dorsum - 3rd Digit (Toe), Lateral for 12/01/23, 12/07/23, 12/13/23, 12/27/23, 01/03/24, 01/15/24, 01/25/24, 02/02/24, 02/09/24. 02/21/24, 02/29/24. Unit Director #95 confirmed Resident #46's wound was assessed by VOHRA wound solutions on 1/22/23 as a skin tear of the left dorsal foot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 42 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/26/24 at 2:47 P.M., an observation of Resident #253's room noted there was an intravenous (IV) bag (500 milliliters) of 0.9% Sodium Chloride and tubing hanging from an IV pole against the wall across from his bed. The IV tubing still had the IV catheter attached at the end of it and the IV catheter was exposed and noted to have dried blood in it. The resident's Power of Attorney (POA), who was in the room at the time of the observation, revealed the resident was given IV fluids about three days ago and the IV bag and tubing had been hanging there since then. He indicated there was blood still in the end of the tubing in the IV catheter. Residents Affected - Some A review of Resident #253's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included vascular dementia, syncope and collapse, presence of a right artificial knee joint, and aftercare following joint replacement surgery. A review of Resident #253's physician's orders revealed an order for 0.9% Sodium Chloride with instructions to use 500 milliliters (ml) at 75 ml/ hour one time only for one day for hypotension (low blood pressure). The order had been given on 02/23/24. A review of Resident #253's progress notes revealed a nurse's note dated 02/23/24 at 11:58 P.M. that indicated the resident had a syncopal episode earlier on day shift with the on-call physician's service being contacted. An order was received for the infusion of 0.9% Sodium Chloride. The nurse's note indicated the resident pulled out the IV on the evening shift. The on-call physician's service was contacted again and an order was received to have the IV put back in place. Critical care placed the IV back into place, but the resident did not want the IV in and had pulled it out a second time. The IV was not ordered to be replaced a third time and the nurse was just given instructions monitor the resident's blood pressure and to call back if his blood pressure was low. On 02/26/24 at 2:54 P.M., an interview with RN #112 revealed Resident #253 was given IV fluids last Friday (02/23/24). She was not aware the IV bag and tubing was still hanging in the resident's room and had not been properly disposed of after it's removal. She was asked to go to the resident's room and she verified the IV bag and tubing was still hanging from the IV pole that was left in the resident's room. She also noted the IV catheter that was attached to the end of the tubing was exposed and had dried blood inside the catheter. She stated the IV bag and tubing should have been discarded and not left in his room, after it had been discontinued and removed. She stated she would remove it from the room and properly dispose of it. A review of the facility's policy on short peripheral intravenous catheter removal revised 06/01/21 revealed the procedure was to be performed by a licensed nurse according to state law and facility policy. The procedure guide included the need to dispose of used supplies per facility policy. Based on observation, interview, record review, and policy review the facility failed to maintain contact precautions for Resident #55, and failed to provide hand washing between different routes of medication administration for Resident #397 who both resided on the [NAME] unit. This affected two residents (Resident #55 and #397) and had the potential to affect the additional 22 residents (#257, #52, #247, #254, #256, #78, #259, #251, #51, #260, #255, #258, #248, #262, #73, #246,, #89, #261, #76, #21, #250, #252) residing on the [NAME] unit. In addition, the facility failed to properly dispose of Intravenous (IV) materials for Resident #253 affecting one resident (#253) of 25 residents reviewed for infection control. The facility census was 93. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 43 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0880 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Record review for Resident #55 revealed an admission date of 02/16/24 with diagnoses including unspecified mycosis, diabetes mellitus type two, and a methicillin resistant staphylococcus aureus (MRSA) infection as the cause of the disease, and bacteremia. Residents Affected - Some Review of the physicians order dated 02/20/24 for Resident #55 revealed an order to maintain contact (precautions) every shift with all activities, meals, therapy and services to be provided in the resident's private room due to MRSA Bacteremia until 03/16/2024. Interview was conducted on 02/26/24 at 11:50 A.M. with Resident #55 in his room. Resident #55 said he had MRSA in his wounds and required an antibiotic 24 hours a day as treatment. Observation at the time of the interview revealed he had IV antibiotics running, and did not have signage on his door indicating his was on contact precautions. Personal protective equipment (PPE) such as gowns, gloves, masks were also not available outside of the resident's room. Interview on 02/26/24 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #117 revealed Resident #55 had not been on contact precautions for the time that she has been here today. She confirmed she had been providing his care without the use of PPE. Interview on 02/26/24 at 2:46 P.M. with Unit Director #28 confirmed Resident #55 should be on contact precautions. She stated she knew the PPE was on his door at some point and was not sure when or why it was removed. Review of the facility policy, Transmission Based Precautions (TBP) dated 8/20/14 revealed TBP are implemented for residents known or suspected to be infected or colonized with an infectious agents requiring additional control measures based on transmission route by nurses or physicians. The procedure for contact precautions indicated the facility will place an isolation box to door with a sign, isolation linen and trash receptacles. The process started by performing hand hygiene before entering the room, wear protective gloves when entering room, touching residents intact skin, surface or articles in close proximity. 2. Review of Resident #397's medical record revealed an admission date of 02/27/23. Diagnoses included type two diabetes mellitus, anxiety, asthma, and unspecified disorder of eye and adnexa (eyelids, conjunctival sac, lacrimal draininage system and gland). Review of Resident #397's orders with a start date of 02/28/24 revealed medication orders including Loratadine (allergy medication) Oral Tablet 10 Milligrams (mg),Vitamin D3 Oral Tablet 10 mg, Aspirin (blood thinner) 81 mg tablet, Insulin Lispro Injection Solution 100 Unit/ML (Insulin Glargine), Vitamin B12 100 micrograms, Prednisolone acetate ophthalmic suspension 1%, Lidocaine (pain patch) external patch 4%, Duloxetine (antidepressant) HCL 40 mg, Amiodarone (antiarrhythmic) HCL 400 mg, Losartan potassium (blood pressure medication) 100 mg , Baclofen (muscle relaxer) 5 mg , Buspar (anti-anxiety) 5 mg, Hydralazine (blood pressure) HCL 50 Mg, Metoprolol Tartrate (blood pressure) 75 Mg, and Apixaban (anti-clotting) 5 mg. Review of Resident #397's Medication Administration Record revealed the following administrations for 02/28/24: Aspirin 81 milligrams (mg) one time a day, Duloxetine HCL 40 mg one time a day, Lidocaine External Patch 4% , Loratadine 10 mg one time a day, Losartan Potassium 100 mg one time a day, Prednisolone Acetate Ophthalmic Suspension 1% (Prednisolone Acetate) one time a day, Vitamin B12 1000 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 44 of 45 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 365026 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wexner Heritage House 1151 College Avenue Columbus, OH 43209 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some micrograms (mcg) one time a day, Vitamin D3 25 mcg one time a day, Insulin Glargine 100 unit/milliliter with meals, Amiodarone 400 mg, Baclofen 5 mg, Buspar 5 mg, Hydralazine HCL 50 Mg, Metoprolol Tartrate 75 Mg and Apixaban 5 mg Observation on 02/28/24 at 8:59 A.M. revealed Licensed Practical Nurse (LPN) #52 was preparing to administer medications to Resident #397. LPN #52 preformed hand hygiene and placed gloves on before entering Resident #397's room, LPN #52 placed the residents medication cup on the bedside table. This cup consisted of Amiodarone, Prednisolone, Aspirin, Baclofen, Buspar, Duloxetine, Hydralazine, Loratadine, Losartan Potassium, Metoprolol, Vitamin B12, Vitamin D3 and Apixaban. LPN #52 placed Resident #397's oral medication on the bedside table, and the resident took them without assistance. When finished, LPN #52 grabbed a tissue for the resident and gave Resident #397 eye drops containing Prednisolone acetate without changing her gloves. With the same contaminated gloves, LPN #52 opened the package containing the lidocaine patch, discarded the exterior container in the garbage, and applied the patch to Resident #397 left arm. After application, LPN #397 disposed of the patch's supplementary packaging. LPN #52 cleansed Resident #397's finger with an alcohol wipe before proceeding to obtain a blood sugar. Once completed, LPN #52 wrapped the glucometer in a paper towel. LPN #52 exited the room, placed the glucometer down and then removed the initial gloves she wore prior to completing the residents oral medication, transdermal medication, eye drops, and blood sugar and then performed hand hygiene. Interview on 02/28/24 at 9:30 A.M. with Unit Director #28 confirmed the follow expectations of staff when administering medications. Staff should perform hand hygiene after entering a residents room. Introduce self to resident and explain why the staff is present, when ready for medication administration staff should perform hand hygiene and place clean gloves on. Once complete with medication administration staff should remove gloves and perform hand hygiene. If a staff member is performing different routes of medication administration for a resident it is expected, they remove soiled gloves and perform hand hygiene before moving to next administration route. Unit Director #28 confirmed staff should perform hand hygiene and place clean gloves before checking residents blood sugar. Interview on 02/28/24 at 10:14 A.M. with LPN #52 confirmed before different routes of medication administration hand hygiene and placement of clean gloves were not conducted. LPN #52 confirmed removal of soiled gloves were not conducted between various routes (oral, eye and transdermal) of medication administration. LPN #52 confirmed hand hygiene was not conducted before obtaining Resident #397's blood sugar. Record review of Blood Glucose Monitoring/POC Device issued on 09/02/21 revealed staff are required to apply non-sterile gloves prior to puncture. When puncture is complete staff shall remove gloves and perform hand hygiene. Record review of administering skin application effective on 01/04/23 requires staff to apply new clean gloves before applying topical agent. Record review of administering eye medications effective on 01/04/23 requires staff to apply clean gloves before instilling eyes drop into a resident's eyes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 45 of 45