Inspection·October 23, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few also had a pressure sore to the buttocks. Resident #85 answered questions and did not appear fearful during questioning. Resident #85 was transported to the hospital for examination. Review of the schedules for 09/03/25 and 09/04/25 revealed Certified Nursing Assistant (CNA) #201 was the only male working. Review of the employee list revealed no males with the name Resident #85 provided. The list was also reviewed for names beginning with the same letter and names similar to the one provided. However, none were identified.A handwritten statement (no date) written by Registered Nurse (RN) #204 revealed Resident #85 reported something happened the night before. Resident #85 stated a black, short haired man of normal size had provided care for Resident #85 before and had taken the trash out. Resident #85 had to go to the bathroom and believed the male helped Resident #85 on the bed, forced Resident #85's clothes off, made Resident #85 lie down and got on top of her and tried to put his penis in her. The male left on his own and Resident #85 was washed up with soap. A skin assessment revealed Resident #85 had a hematoma to the left side of upper head, bruising to bilateral arms, left upper hip area, back of the left shoulder, and to the bilateral back of the knees. A name provided by the resident was written on the statement, but a different spelling. A handwritten statement (no date) written by LPN #207 revealed Resident #85's daughter stated Resident #85 told her, You would not believe what goes on at night. I was raped. Resident #85 stated she did not want to cause trouble and was over it. Resident #85 stated it was not last night but the night before (Wednesday, 09/03/25). A typed statement by the Director of Nursing (DON) of a telephone interview with LPN #202 on 09/05/25 (typed as 06/05/25 and verified by the DON to be the incorrect date typed) at 6:30 P.M. revealed CNA #201 reported the night of 09/03/25 Resident #85 seemed to have a decline since the last time CNA #201 had worked. Resident #85 had frequent loose stools and was kept clean and dry. There were no concerns with care by CNA #201. A typed statement by DON of interview with CNA #203 on 09/05/25 (typed as 06/05/25 and verified by the DON to be incorrect date typed) at 7:00 P.M. revealed CNA #203 did not provide care for residents on 09/03/25 and 09/04/25 and did not witness any inappropriate care by CNA #201.A general nurses note dated 09/06/25 at 3:05 P.M. revealed Resident #85's family stated Resident #85 was admitted to the hospital for dehydration. The family requested a room closer to the nurse's station, no men enter Resident #85's room, and a camera be put in Resident #85's room. A rape kit had been completed at the hospital, but the results could take up to six months. The family stated a police report had been filed. A handwritten statement by CNA #201 dated 09/09/25 revealed while administering care, he noticed Resident #85 was sicker than she had been when he left on Monday, 09/01/25. On 09/04/25 between 6:00 P.M. and 6:00 A.M. Resident #85 kept having a bowel movement. CNA #201 had to do incontinence care on Resident #85 three times without any problems. Around 3:00 A.M., Resident #85 reported she did not feel well. Resident #85 did not say why and only closed her eyes. Resident #85 had a choking episode on 09/03/25 and 09/04/25 when medications were administered and on 09/04/25 the choking episode lasted about an hour. CNA #201 thought this tired Resident #85 out and she did not talk to CNA #201 anymore that night. (This episode was not documented in the medical record)An interview on 10/16/25 at 8:30 A.M. Administrator verified CNA #201 was the only male working on 09/03/25 and 09/04/25. An interview on 10/16/25 at 11:25 A.M. with the Administrator stated at first Resident #85 reported the assault occurred on 09/04/25 and then changed to 09/03/25. The Administrator stated at first it was believed Resident #85 reported the male was short and CNA #201 was not short. The Administrator verified the date of 09/03/25 and clarification that Resident #85 said the male had short hair and was normal size was discovered early in the investigation when Resident #85 and her daughter were interviewed. The Administrator verified the only staff interviewed about the allegation were the staff working night shift on 09/03/25. The Administrator verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 2 of 9 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 10/23/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the staff providing care for Resident #85 during the day on 09/04/25 were not interviewed about Resident #85's reporting any concerns or if Resident #85's demeanor was different on 09/04/25. An interview on 10/16/25 at 10:08 A.M. with Resident #85's husband verified a rape kit was completed at the hospital for Resident #85, but the hospital stated it could take months to get the results back. Resident #85 had discharged back to an assisted living facility with the husband after the hospital stay. Resident #85's husband stated he was not sure if a sexual assault occurred but wanted to make sure it was thoroughly investigated. An interview on 10/16/25 at 12:17 P.M. with Registered Nurse (RN)/Wound Nurse #204 verified the skin assessment on 09/05/25 revealed Resident #85 had bruising behind both knees that had not been previously identified. An interview on 10/20/25 at 1:56 P.M. the Administrator verified the investigation was completed on 09/08/25 but CNA #201 was permitted to return to work on 09/08/25 at 6:00 P.M. The Administrator verified there was not an investigation about the bruising to the back of Resident #85's knees. A follow- up interview on 10/21/25 at 10:04 A.M. with the Administrator verified that a statement was not obtained from CNA #201 until 09/09/25 when CNA #201 returned to work the evening of 09/08/25.An interview on 10/23/25 at 8:19 A.M. with LPN #202 stated Resident #85 had loose stools and coughing when taking anything orally, but this was not uncommon for Resident #85. LPN #202 did not feel there was a change in condition that required a doctor to be notified. An interview on 10/23/25 at 9:20 A.M. RN #204 verified she wrote out Resident #85's statement. RN #204 verified Resident #85 reported the male staff member had short hair, not short in stature. RN #204 verified Resident #85 had given the name (provided) and RN #204 had written the name on the statement. RN #204 again verified Resident #85 had bruising to the back of the legs, but the bruising did not seem to be suspicious and there was no further documentation of the bruising such as pictures, measurements, or description. The Abuse, Mistreatment, Neglect, Exploitation, and Misappropriate of Resident Property policy dated 01/25/25 revealed the investigation protocol included interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and/or alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. (For example, consider interviews with all employees on the shift or unit). Review all relevant medical report/records as applicable. Evidence of the investigation should be documented in accordance with Quality Assurance protocols. This is an incidental finding discovered during the complaint investigation. Event ID: Facility ID: 365026 If continuation sheet Page 3 of 9 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 10/23/2025 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 closed record review, interview, and policy review, the facility failed to complete treatments, provide medications and obtain laboratory testing as ordered by the physician. This affected one (#86) of three residents reviewed for condition change. The facility census was 84. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with diagnoses that included but not limited to acute osteomyelitis to the left ankle and foot, anorexia, sepsis due to Methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open wound on the left foot. The resident was discharged on 09/03/25.a. Review of the Plan of care dated 08/24/25 revealed Resident #86 was at risk for skin breakdown and development of pressure injury related to hospitalization, and left foot wound due to partial second metatarsal amputation. Review of physician order dated 08/24/25 revealed Resident #86's left foot was to be cleansed with normal saline, have betadine (antiseptic) applied to the wound bed, covered with a four-inch by four-inch dry sterile gauze, and a single four-inch by four-inch gauze placed at the dorsal food and anterior ankle, then wrapped with a gauze roll and a four-inch elastic bandage with very light compression every day shift. A Skin and Wound evaluation dated 08/25/25 revealed Resident #86 had a surgical wound with seven sutures to the left plantar second digit toe (amputation) that was present upon admission. The wound measured 4.1 centimeters long and 0.5 cm wide. Review of the treatment administration record (TAR) revealed no evidence of the treatment being completed on 08/27/25, 08/28/25, 09/01/25, and 09/03/25. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had severe cognitive impairment. The MDS also revealed Resident #86 had an infection of the foot/surgical wound.An interview on 10/23/25 at 10:51 A.M. with the Director of Nursing (DON) verified there was no documentation of the treatments being completed to Resident #86's left foot on 08/27/25, 08/28/25, 09/01/25, and 09/03/25.Wound care treatment guidelines policy dated 03/31/22 revealed documentation of the treatment should be done immediately after the treatment. b. A comprehensive metabolic panel (CMP) laboratory test dated 08/27/25 revealed Resident #86's potassium level was 4.0 milliequivalents (mEq) per Liter (L). The normal reference range for Potassium was 3.5 mEq/L to 5.3 mEq/L.Review of CMP results dated 09/01/25 revealed Resident #86's Potassium was 2.6 mEq/L which was critically low. An order dated 09/02/25 was received for a STAT (immediate) basic metabolic panel (BMP). The BMP dated 09/02/25 revealed Resident #86's potassium was 2.7 mEq which was critically low. A general nurse's note dated 09/02/25 at 10:43 P.M. authored by Licensed Practical Nurse (LPN) #209 revealed Resident #86 potassium was 2.7 mEq. The physician called the supervisor and ordered potassium two bid (twice a day), a day and 1 at 10pm , 3pm, and 1 at 7 pm dose was administered resident tolerated the drugs.A general nurse's note dated 09/03/25 at 12:10 A.M. authored by Registered Nurse (RN) #208 revealed the physician called regarding Resident #86's low potassium level. Resident #86 received evening medication at approximately 9:00 P.M. and vomited soon after. The physician ordered Resident #86 be given Zofran (anti-nausea) four milligrams sublingually. After 30-minutes, Resident #86 was to be administered 40 mEq of potassium. If Resident #86 was able to tolerate these medications 40 mEq of potassium was to be administered at 3:00 A.M. and 7:00 A.M. If Resident #86 was unable to tolerate the medication, the physician needed to be notified, and Resident #86 may need sent to the hospital. RN #208 relayed the orders to LPN #209 to place the orders and order the labs. LPN #209 verbalized understanding. Review of the medical record revealed no evidence of Zofran or Potassium 40 mEq being administered. There was no evidence the medications were removed from the facility emergency stock Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 4 of 9 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 10/23/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete medications.Further review revealed a BMP was completed on 09/03/25 and the resident's Potassium level returned to 4.5 mEq/L. An interview on 10/20/25 at 3:06 P.M. LPN #209 revealed she could not recall information about Resident #86's potassium being administered. An interview on 10/20/25 at 3:16 P.M. RN #208 revealed critical labs were called to the nursing supervisors. RN #208 verified she was notified of the critical labs and relayed the new orders for medications to LPN #209. RN #208 verified LPN #209 should have entered the orders and administered the Zofran and potassium as ordered. An interview on 10/23/25 at 10:51 A.M. DON verified the nurse note by LPN #209 dated 09/02/25 at 10:43 P.M. was confusing. DON verified there was no evidence in the medical record of the orders for Zofran or potassium being written or administered to Resident #86 as ordered on 09/02/25 or 09/03/25. Physician Orders policy dated 01/03/22 revealed a provider many give a medical order over the telephone. The nurse will transcribe the order into the electronic medical record. The nurse that the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. The medication administration record should automatically be updated with the new orders if a schedule has been assigned. This deficiency represents non-compliance investigated under Complaint Number 2609622 Event ID: Facility ID: 365026 If continuation sheet Page 5 of 9 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 10/23/2025 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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, hospital record review, policy review and interview the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers.Actual Harm occurred on 09/03/25 when Resident #86, who had resided in the facility less than 30 days, was cognitively impaired and required staff assistance with activities of daily living, was assessed to have an unstageable pressure ulcer to the sacrum with necrosis requiring debridement. Resident #86 had been admitted to the facility on [DATE] with a skin alteration to the coccyx that the facility failed to complete a comprehensive wound assessment of, failed to provide appropriate/adequate interventions for and failed to ensure the facility wound physician and wound nurse were timely notified of to prevent the deterioration of the alteration to an unstageable pressure ulcer. This affected one resident (#86) of three residents reviewed for pressure ulcers. Findings include: Review of the closed medical record revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis left ankle and foot, anorexia, sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, osteoarthritis of the knee, dementia, irritant contact dermatitis, and open wound on left foot. Resident #86 was discharged from the facility on 09/03/25 to the hospital and did not return to the facility following the hospitalization. Review of the hospital record dated 08/24/25 revealed the resident was being discharged to the facility and had Moisture Associated Skin Damage (MASD), skin inflammation caused by prolonged exposure to moisture, leading to skin breakdown and irritation, present to the buttocks with Triad cream (sterile, zinc-oxide base, hydrophilic paste to create a moist environment that aids autolytic debridement) ordered for treatment. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had severe cognitive impairment. The assessment revealed Resident #86 required maximal (staff) assistance with bed mobility. The MDS also revealed Resident #86 was always incontinent of bowel and bladder. The initial assessment completed did not indicate the resident was admitted to the facility with any type of skin alterations. A care plan dated 08/24/25 revealed Resident #86 was at risk for skin breakdown and development of pressure injury. The care plan included Resident #86 had a left foot wound related to partial second metatarsal amputation, moisture associated skin damage (MASD), and redness under both breasts. Interventions included assisting with turning and repositioning every two hours and as needed, assisting with maintaining skin clean and dry daily, monitoring for MASD/redness and left foot wound for signs and symptoms of infection every shift, completing treatments as ordered, weekly skin assessments as scheduled, and the wound physician/nurse to evaluate and treat as ordered. Record review revealed no documented evidence staff were encouraging or providing turning and repositioning every two hours. In addition, there was no evidence Resident #86 was noncompliant with care or interventions. A physician order dated 08/24/25 revealed Resident #86 was ordered Triad paste to buttocks for incontinence every day and night shift. The resident also had an order for HydraGuard (moisture barrier) to be applied every shift after incontinent episodes for prevention. Review of the treatment administration record (TAR) revealed the treatments were completed per orders.A Braden Scale for Predicting Pressure Sore Risk dated 08/24/25 revealed Resident #86 scored a 14 out of a possible 18 which indicated Resident #86 was at moderate risk for pressure ulcer development. A skin and wound evaluation dated 08/24/25 at 12:01 P.M. included Resident #86 had an unstageable pressure wound to the coccyx. The evaluation noted the wound was present upon admission and measured 9.4 centimeters (cm) long and 0.94 cm wide. The author of the assessment did not sign the document or Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 6 of 9 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 10/23/2025 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 - Actual harm Residents Affected - Few provide a description of the coccyx wound. A black and white photo dated 08/24/25 was provided for the surveyor from the medical record. No unstageable wound could be identified to the resident's coccyx or buttocks. The quality of the photograph did not support the said stage of the wound.An admission Screener dated 08/24/25 at 3:25 P.M., completed by LPN #200, revealed Resident #86 had an open area to the coccyx. There was no description or staging of the wound despite the document having an anatomical drawing, descriptions of wound staging and areas to document wound measurements. Review of hospital documentation and the facility skin assessments (MDS, skin and wound evaluation, admission screener) for this area were inconsistent at the time of admission, noting the resident had MASD, an open area and an unstageable pressure ulcer to the sacrum. No additional documentation or evidence was provided by the facility to support a comprehensive and accurate assessment, including description and staging of the ulcer was completed. A physician order dated 08/26/25 revealed Resident #86 was ordered Triad paste to be applied to the resident's sacrum for MASD every day and night shift. This order was changed to reflect MASD and not incontinence from the original order dated 08/24/25. The treatment administration record (TAR) revealed Registered Nurse (RN) #200 signed a skin assessment was completed on 08/29/25. Review of the medical record revealed no documentation of the skin assessment and no evidence wound photographs were taken on this date.A physician order dated 09/02/25 revealed Resident #86 was ordered an alternating air mattress for pressure relief. No nutrition interventions were implemented despite the residents increased energy demands with a healing surgical wound and skin alteration to her coccyx. There was no documentation of the wound at this time.Review of the nursing progress notes dated 08/24/25 through 09/02/25 (prior to the wound physician's visit on 09/03/25) revealed no comprehensive documentation of the resident's wound to her coccyx or buttocks, no documentation of the resident's compliance or noncompliance with pressure relieving interventions or evidence any pressure relieving interventions were added except the air mattress (which was ordered on 09/02/25). An initial wound evaluation by Wound Physician #301 dated 09/03/25 revealed Resident #86 had an unstageable wound to the sacrum with necrosis. The wound measured six cm long by 9.5 cm wide with 0.2 cm depth. There was moderate serous exudate with 40-percent thick adherent necrotic tissue and 30-percent slough. The wound was debrided to remove necrotic tissue and establish the margins of viable tissue. A new order was received for Mesalt (a sodium chloride dressing to stimulate the cleansing of discharging wounds) and gauze bordered dressing to be applied to the wound daily and as needed if saturated, soiled, or dislodged. Recommendations included to off-load the wound, reposition per facility protocol, and a low air loss mattress. An interview on 10/21/25 at 10:29 A.M. with Wound Physician #301 revealed he saw all residents with any skin concerns including MASD, open areas, skin tears or pressure ulcers weekly, in the facility. The physician denied being aware or informed of any type of skin impairment/pressure ulcer for Resident #86 prior to 09/03/25. Wound Physician #301 revealed he assessed the resident's pressure ulcer on 09/03/25 and noted it to be unstageable with the measurements noted above (prior to the ulcer being debrided). The physician revealed he had been in the facility on 08/27/25 but had not been informed Resident #86 had any skin impairment on her buttock/sacrum at that time. The physician indicated it was unclear the type of wound that was present (prior to the resident being seen on 09/03/25) given the inconsistencies with the facility skin assessments but stated the resident should have been evaluated by him when the skin alteration/pressure ulcer to the coccyx was first identified as to not delay treatment and to ensure adequate interventions were in place. On 10/20/25 at 3:58 P.M., interview with the Director of Nursing (DON) verified RN #200 stated she completed the weekly skin assessment on 08/29/25 but failed to take wound photos or document the description, including measurements and staging, of the wound. During an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 7 of 9 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 10/23/2025 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 - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interview on 10/21/25 at 10:51 A.M. the Director of Nursing (DON) revealed there was confusion over the type of area Resident #86 had to her buttock/sacrum/coccyx. The DON verified staff labeled the alteration as MASD, an open area, and an unstageable pressure. The DON verified neither MDS assessment or care plan reflected the resident had an unstageable pressure ulcer to the coccyx/sacrum upon admission. The DON also revealed the facility wound nurse was not notified of the resident's skin alteration on admission and expectation is for the wound nurse to be notified. The DON stated the discrepancies in the resident's wound assessment affected the facility's ability to determine if the resident needed additional intervention, care and assessment from the facility wound nurse or assessment from the facility consulting wound doctor. The DON verified RN #200 worked with the resident and felt the RN did assess the resident but failed to document the resident's wound assessment or take photographs per the facility policy/procedures. On 10/21/25 at 12:13 P.M. Administrator indicated the resident's MDS assessment was updated to reflect Resident #86 was admitted with an unstageable pressure ulcer (despite there being no documented evidence the resident had an unstageable pressure ulcer on admission according to the assessments provided).An interview on 10/23/25 at 9:25 A.M. RN/Wound Nurse #204 revealed the floor nurses take pictures of the wounds and should do measurements and a description of the wound. RN/Wound Nurse #204 verified LPN #200 only documented the measurements and did not document slough or any other description of the wound. RN/Wound #204 stated any skin concerns should have a wound consult order put in. This order would identify the resident needed to be seen by the facility wound nurse and the outside wound doctor. The nurse verified the resident's pressure ulcer declined from admission on [DATE] to 09/02/25 when she evaluated the wound and implemented the air mattress. The wound nurse did not have any documentation of the wound on 09/02/25 to provide. The wound nurse stated the Wound Doctor should have seen the resident's wound when he visited on 08/27/25 and she should have been notified of the resident's skin alteration on admission.An interview on 10/23/25 at 11:19 A.M. LPN #200 stated pictures were taken of any skin open areas, but LPN #200 does not think she would have staged a wound. LPN #200 could not recall any specific details about Resident #86 but verified she would have taken a picture if there was an open area but could not recall any other details about the resident's wound and verified she did not document an assessment of the resident's skin to provide her additional details. Wound Care Treatment Guidelines dated 03/31/22 revealed a weekly assessment should be done on all wounds requiring treatment. This should include measurements and a description. Documentation of the treatment should be done immediately after the treatment. This deficiency represents non-compliance investigated under Complaint Number 2609622. Event ID: Facility ID: 365026 If continuation sheet Page 8 of 9 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 10/23/2025 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, and policy review, the facility failed to ensure laboratory testing was completed per physician order. This affected one (#86) of three residents reviewed for condition change. The facility census was 84. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE] with diagnoses that included but not limited to acute osteomyelitis to the left ankle and foot, anorexia, sepsis due to Methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open wound on the left foot. The resident was discharged on 09/03/25.A comprehensive metabolic panel (CMP) laboratory test dated 08/27/25 revealed Resident #86's potassium level was 4.0 milliequivalents per liter (mEq/L) of blood. The normal reference range for Potassium was 3.5 mEq/L to 5.3 mEq/L.Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had severe cognitive impairment. CMP laboratory results dated [DATE] revealed Resident #86's Potassium was 2.6 mEq/L which was critically low. An order dated 09/02/25 was received for a STAT (immediate) basic metabolic panel (BMP) laboratory test. The BMP dated 09/02/25 revealed Resident #86's potassium was 2.7 mEq/L which was critically low. A general nurse's note dated 09/02/25 at 10:43 P.M. authored by Licensed Practical Nurse (LPN) #209 revealed Resident #86 potassium was 2.7 mEq/L. The physician called the supervisor and ordered potassium.A general nurse's note dated 09/03/25 at 12:10 A.M. authored by Registered Nurse (RN) #208 revealed orders were received to administer potassium chloride 40 mEq orally thirty minutes after Zofran (anti-nausea) and then again at 3:00 A.M. and 7:00 A.M. If Resident #86 was unable to tolerate the medication, the physician needed to be notified, and Resident #86 may need sent to the hospital. The physician also ordered a CMP and Magnesium level to be drawn on 09/03/25. RN #208 relayed the orders to LPN #209 to place the orders and order the labs. LPN #209 verbalized understanding. Review of the closed medical record revealed a BMP was completed on 09/03/25 and the resident's Potassium level returned to 4.5 mEq/L. However, a CMP and Magnesium were not completed.An interview on 10/20/25 at 10:51 A.M. Director of Nursing (DON) verified orders for CMP and Magnesium blood work for Resident #86 were not completed as ordered (the RN and LPN did not enter the order in the medical record).An interview on 10/20/25 at 3:06 P.M. LPN #209 revealed she could not recall information about Resident #86's potassium or ordered blood work.An interview on 10/20/25 at 3:16 P.M. RN #208 revealed critical labs were called to the nursing supervisors. RN #208 verified she was notified of the critical labs and relayed the new orders for medications and blood work to LPN #209 for the LPN to address.Physician Orders policy dated 01/03/22 revealed a provider many give a medical order over the telephone. The nurse will transcribe the order into the electronic medical record. The nurse that the physician gave the order to will be responsible for executing the order or provide for the safe hand-off to the next nurse. Contact laboratory services as required to execute the medical order. Laboratory Services and Reporting policy dated 04/2022 revealed the community provides or obtains laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. This deficiency represents non-compliance investigated under Complaint Number 2609622. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365026 If continuation sheet Page 9 of 9