Health inspection·October 5, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on medical record review and staff interview, the facility failed to provide evidence that the state ombudsman was notified of resident discharges. This affected three residents (Resident #17, Resident #88, and Resident #89) of four resident discharges reviewed. Findings Include: Review of Resident #17 medical records revealed he was immediately discharged from the facility on 02/24/20, after he was arrested. Review of Resident #88 medical records revealed she was discharged from the facility on 07/16/21, when she was sent to the hospital. Finally, review of Resident #89 medical records revealed she was discharged home immediately on 08/10/21. While reviewing all three resident medical records, there was no evidence that the facility sent the discharge information to the state long term care ombudsman office. Interview with Administrator on 09/30/21 at 1:15 P.M. confirmed that the facility could not produce evidence they sent the monthly discharges to the state long term care ombudsman's office. She stated they could look through historical documentation, but it could be a challenge to find. Also, the staff person responsible for sending the information to the state long term ombudsman's office was not in the facility at this time, so they could not locate that information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 observations, staff interview, record review, and facility policy review, the facility failed to ensure two residents (Residents #1 and #60) had their hair washed as scheduled and failed to ensure one resident (Resident #62) was shaved per preference. The affected three residents (Residents #1, #60, and #62) of five residents reviewed for activities of daily living (ADL's). Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, muscle weakness, type II diabetes mellitus, encephalopathy, disorientation, adult failure to thrive, low back pain, fibromyalgia, rheumatoid arthritis, anxiety disorder, major depressive disorder, and other abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21, revealed Resident #1 had mildly impaired cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bathing. Resident #1 had impairments on both sides to her lower extremities. Review of the nurse's notes from 09/16/21 through 09/30/21 revealed no documentation related to resident's hair being washed. Review of the plan of care for Resident #1 dated 09/16/21 revealed the resident had an activity of daily living (ADL) self care deficit as evidenced by poor functional mobility related to physical limitations and encephalopathy. Interventions included to assist to bathe/shower as needed, assist with daily hygiene/grooming/dressing/oral care and eating as needed. Review of the bathing task for Resident #1 dated from 09/16/21 through 09/30/21 revealed question number two of the task was hair washed? with options Y for yes and BH for hair washed by beautician. The resident was scheduled for showers or bed baths on Mondays and Wednesdays and as needed (PRN). The task showed the resident received bed baths and NA or Not Applicable was documented for question two for each bed bath that was provided on 09/17/21, 09/20/21, 09/22/21, 09/27/21, 09/28/21, and 09/29/21. The resident refused a bed bath or shower on 09/19/21. Observations on 09/27/21 at 12:38 P.M. and 09/28/21 at 1:05 P.M. of Resident #1 revealed the resident was laying in bed, dressed in a hospital gown, and her hair appeared greasy and unwashed. Interview on 09/27/21 at 12:38 P.M. with Resident #1 revealed the resident had not received a shower or bed bath and had her hair washed in approximately ten days. Interview on 09/30/21 at 10:40 A.M. with Director of Nursing (DON) #233 confirmed the staff were supposed to answer question two of the bathing task with a Y for yes or N for no. Not applicable should not be documented to answer question two. DON #233 confirmed there was no additional documentation that showed Resident #1's hair had been washed since her admission on [DATE]. Review of the facility policy, Bathing, revised 07/2016, revealed the bed bath procedure was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fill basin with warm water and begin bathing. Adjust water temperature to patient's comfort. A complete bath involved washing the patient's entire body and a partial bath included bathing face, hands, underarms, perineum, back, and buttocks or assistance as needed. Comb and brush hair. 2. Review of the medical record for Resident #60 revealed an admission date on 02/19/21 with medical diagnoses including type II diabetes mellitus with diabetic neuropathy, peripheral vascular disease, heart failure, chronic kidney disease, unspecified asthma, unspecified mood disorder, major depressive disorder, anxiety disorder, muscle weakness, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/25/21, revealed Resident #60 had intact cognition per staff assessment and was independent with making decisions for daily life. The resident required extensive assistance from two staff to complete activities of daily living (ADLs) and required one staff to assist with bathing activity. Review of the nurse's notes for Resident #60 dated from 07/01/21 through 09/30/21 revealed no documentation related to the resident's hair being washed. Review of the plan of care for Resident #60 dated 07/27/21 revealed the resident had an ADL self care deficit as evidenced by inability to care for herself related to disease process of end stage renal disease (ESRD), chronic lower extremity weakness, physical limitations, morbid obesity, and limited range of motion (ROM). Interventions included: assist to bathe/shower as needed and assist with daily hygiene/grooming/dressing/oral care/eating as needed. Review of the bathing task for Resident #60 for July 2021, August 2021, and September 2021, revealed question number two of the task was hair washed? with options Y for yes and BH for hair washed by beautician. The resident was scheduled for showers or bed baths on Mondays, Wednesdays, Fridays, and as needed. Review of July 2021 bathing task revealed the resident refused a bed bath on 07/02/21 and 07/05/21. She was out of the facility on 7/14/21, 07/16/21, 07/19/21, 07/21/21. There was no documentation that a bed bath had been offered or given on 07/23/21 or 07/26/21. On 07/07/21, 07/08/21, 07/09/21, 07/10/21, 07/12/21, 07/27/21, 07/28/21, and 07/29/21 the resident received a bed bath but NA or not applicable was noted for question two. Review of August 2021 bathing task revealed NA or not applicable was documented for question two for all PRN bed baths provided to Resident #60 as well as on 08/06/21, 08/09/21, and 08/13/21. The resident refused a bed bath on 08/04/21, 08/11/21, 08/18/21, 08/20/21, 08/23/21, 08/27/21, and 08/30/21. The resident's hair was washed on 08/02/21 and 08/16/21. Review of September 2021 bathing task revealed there was no specified documentation related to washing the resident's hair completed. Observation on 09/28/21 at 8:43 A.M. of Resident #60 revealed the resident was laying in bed, dressed in a hospital gown, and her hair appeared greasy and unwashed. Interview on 09/28/21 at 8:43 A.M. with Resident #60 revealed the resident received bed baths per preference because she did not like the hoyer lift. The resident stated her hair was not washed with bed baths and she had not had her hair washed in approximately two months. The resident stated she wanted her hair washed more frequently. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/30/21 at 10:40 A.M. with Director of Nursing (DON) #233 confirmed the staff were supposed to answer question two of the bathing task with a Y for yes or N for no. Not applicable should not be documented to answer question two. DON #233 confirmed there was no additional documentation that showed Resident #60's hair had been washed with scheduled or PRN bed baths. Review of the facility policy, Bathing, revised 07/2016, revealed the bed bath procedure was to fill basin with warm water and begin bathing. Adjust water temperature to patient's comfort. A complete bath involved washing the patient's entire body and a partial bath included bathing face, hands, underarms, perineum, back, and buttocks or assistance as needed. Comb and brush hair. 3. Review of the medical record for Resident #62 revealed an initial admission date of 03/05/19 and a re-entry date of 08/20/21. Diagnosis included muscle weakness, dementia without behavioral disturbances, and abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS), 3.0 assessment, dated 08/27/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09 indicating a moderately impaired cognition for daily decisions making ability. No behaviors were noted at the time of the assessment. The resident requires extensive assistance from two staff members for bed mobility, transfers, locomotion on and off the unit, toileting needs, and personal hygiene. The resident was noted to have an impairment to his bilateral lower extremities and required the assistance of a wheelchair for locomotion. Resident #62 was noted to always be incontinent of bowel and bladder function. Resident #62 noted it was very important to choose between a sponge bath, bed bath, or shower. Review of the shower schedule for Resident #62 revealed the resident was scheduled to receive a shower/bath during day shift on Saturday, Tuesday, and Thursday. Review of the nursing and aide completed task from 09/04/21 through 10/02/21 revealed the resident received a bed bath on 09/25/21 and on 09/23/21 and refused bathing on 09/18/21 and then received a shower on 09/11/21. Continued review of this completed task revealed no indication the resident had been shaved to remove any unwanted facial hair. Review of the plan of care, dated 08/12/21, revealed Resident #62 had a activity of daily living (ADL) self care deficit as evidence by need for assistance with ADL's related to disease process and a history of cerebral vascular disease (CVD), weakness, and recent procedure. Interventions include for staff to assist with bathing/shower, grooming, personal hygiene, oral care and dressing as needed and/or requested. Observation on 09/27/21 at 11:30 A.M. of Resident #62 revealed resident sitting in a wheelchair located in his room. Resident #62 was noted to be wear a T-shirt and a pair of shorts and had a pair of non-skid socks on. Resident #62 was noted with short to medium length facial hair. Interview on 09/27/21 at 11:32 A.M. with Resident #62 revealed he prefers to be clean shaved and to not have any facial hair. Resident #62 stated he is not able to shave himself since he does not have an electric razor and was not shaved the last time he received a shower. Interview on 09/29/21 at 3:00 P.M. with the Director of Nursing (DON) revealed there was no evidence to prove Resident #62 had been shaved when receiving a scheduled shower/bath, or shaved anytime in between shower/bath days. The DON also confirmed that residents should be asked if shaving is something they would like to have done daily and especially on shower/bath days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 Review of the facility policy titled, Shaving, dated 01/2011, revealed the purpose of the policy was to provide personal hygiene and grooming needs and remove unwanted facial hair. 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: 365611 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 record review, observation, and interview, the facility failed to provide activities according to Resident #44 and Resident #338's preferences. This affected two residents (Resident #44 and Resident #338) of two residents reviewed for activities that meet the interest and needs of each resident. Residents Affected - Few Findings include: 1. Record review revealed Resident #338 was admitted to the facility on [DATE] with diagnoses including type two diabetes with hyperglycemia, vascular dementia with behavioral disturbance, major depressive disorder, unsteadiness on feet, muscle weakness and other abnormalities of gait and mobility. Review of Resident #338's comprehensive Minimum Data Set (MDS) assessment, dated 09/23/21, revealed the resident was cognitively impaired and required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #49's progress notes. dated 09/20/21, Activities Director (AD) #168 documented the resident enjoyed music, singing, sewing, sitting on the patio, social events, reading, utilizing personal smart phone, religious services, taking walks, and watching movies. Resident only spoke creole. Activity staff would encourage resident to pursue self-directed leisure activities. Activity staff would provide materials as needed or upon request for activities of interest. All activities provided/offered in room due to isolation unit. Review of Resident #338's care plan, dated 09/20/21, revealed the resident preferred not to attend group activities however enjoyed activities such as music, singing, sewing, sitting on the patio, reading the bible, utilizing smart phone, religious activities, shopping, taking walks, and watching movies. Interventions included assist in planning/encourage to plan own leisure-time activities. Provide supplies/materials for leisure activities as needed/requested. Review of Resident #338's Daily Recreation/Activity Participation Documentation log from 09/16/21 to 09/27/21 revealed documentation the resident independently watched television daily and participated in facetime visits (window visits) with family on 09/18/21, 09/20/21 and 09/24/21. No other participation in activities were documented. Several observations were made of the isolation/observation unit from 09/27/21 through 09/30/21, between 8:00 A.M. and 3:00 P.M. and revealed Resident #338 was in her room watching television, with the door closed. Resident #338 was observed to have her smartphone available on the bedside table, and no activity related materials were observed in the resident's room. Interview on 09/29/21 at 1:40 P.M., with AD #168 confirmed Resident #338 had not received activities per her plan of care or her listed preferences. 2. Review of the medical record for Resident #44 revealed an admission date of 08/10/21 and a diagnosis of major depressive disorder single episode, anxiety disorder, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS), 3.0 assessment, dated 08/17/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating a moderately impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognition for daily decision making ability. No behaviors were noted at the time of assessment. Resident #44 required extensive assistance from two staff member for bed mobility and toileting and extensive assistance form one staff member for transfers, locomotion on and off the unit, dressing, and personal hygiene. Resident #44 was noted to have a impairment to her bilateral lower extremities and requires the assistance of a walker and wheelchair for locomotion. Resident #44 required the assistance of a indwelling catheter for bladder elimination and was noted to always be incontinent of bowel elimination. Review of Resident #44's plan of care, dated 08/17/21, revealed the resident enjoyed activities such as watching television (news, movies, reality shows, sports, and drama), listening to music, taking walks, social events, word play, reading, socializing, road trips, baking, utilizing personal smart phone, crochet, and religious services. Interventions included to allow resident time to respond, assist to transport to and from activities of choice, find, offer, and make use of newspaper, magazines, involve in smaller groups, offer/supply large print materials, provide supply materials for pleasure activities as needed and/or requested. Review of Resident #44's Recreation Activity evaluation, dated 08/16/21, revealed the resident liked to spend time relaxing, enjoyed and participated in independent leisure activity-involved, expressed interest in groups, enjoyed to participate in outdoor leisure, liked dogs, walking, being with family and friends, using a tablet, baking, and watching television. Review of the activity log for Resident #44 for September 2021 revealed the resident refused to participate in activities such as playing cards/games, Bingo, resident council, social program, and spiritual/religious activities eight out of the 30 days of September. Resident #44 was noted to complete a puzzle eight out of the 30 days of the month, completed reading/writing activity 18 out of the 30 days of the month, completed socializing two of the 30 days of the month, have visitors two of the 30 days of the month and watched television 16 out of the 30 days of the month. Observation on 09/27/21 at 10:40 A.M. of Resident #44 revealed the resident laying supine in bed, resting with her eyes opened, watching television. Resident #44 was noted to be alert and smiled and waved when addressed. Interview on 09/27/21 at 10:43 A.M. with Resident #44 revealed she really never gets out of bed unless she is going to therapy. Resident #44 claimed she does not attend any group activities due to no one telling her when and/or what was going on. Resident #44 claimed she would be more than happy to attend some of the activities the facility has because she is tired of just watching the television and looking at her tablet. Resident #44 also denied having a activity staff member come to her room and complete one on one activity such as talking, nor has anyone come to her room and offered for her to have something for her to do independently in her room such as a book, work search, puzzles,or crossword. Observation on 09/28/21, 09/29/21, and 09/30/21 from 10:00 A.M. through 3:00 P.M. revealed Resident #44 was sitting in her bed watching television or looking at her phone. Observation of the resident's room revealed no indication that there was materials provided for independent activities. Interview on 09/30/21 at 2:00 P.M. with Activity Director #168 revealed she is the only activity staff member at this time. Activity Director #168 revealed when staff are in the residents rooms providing care, this counted as socializing. Activity Director #168 also confirmed Resident #44 had not been provided with activities that met her preferences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Activity and Recreation Service manual, dated 07/2019, revealed, the purpose of the manual was to serve as a guide in providing an ongoing program of activities designed to accommodate individual patient interests and help enhance physical, mental, and psychosocial well-being according to the comprehensive patient assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 observations, staff interview, record review, and facility policy review, the facility failed to ensure a splint was placed on a resident's (Resident #46) left hand as ordered. The deficient practice affected one (Resident #46) of one reviewed for limited range of motion (ROM). Findings Include: Review of the medical record for Resident #46 revealed an admission date on 06/22/18 with medical diagnoses including cerebral infarction, cognitive communication deficit, aphasia following unspecified cerebrovascular disease, weakness, other lack of coordination, and muscle weakness. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/19/21, revealed the resident was rarely or never understood. Per staff assessment, the resident had severely impaired cognition. The resident required extensive assistance to total dependence on staff to complete activities of daily living (ADL's). Review of the current physician orders for Resident #46 revealed an order with a start date on 10/28/20 for a splint to left hand. Wear during the day and off at night. Monitor for skin integrity/edema every day and night shift to maintain function. Review of the nurse's notes for Resident #46 dated from 07/30/21 through 09/30/21 revealed no documentation related to the use of a hand splint. Review of the plan of care for Resident #46, dated 02/26/19 and last revised on 09/03/21, revealed the resident had an activity of daily living (ADL) self care deficit as evidenced by total dependence related to stroke (CVA) and limited ROM. Interventions included positioning devices: used left hand splint to maintain good body alignment and the resident would tolerate left hand splint use in order to promote skin integrity and positioning throughout the day without distress, and manual therapy: electrical stimulation, diathermy, splinting, therapeutic exercise, and massage. Review of the Visual/Bedside [NAME] Report for Resident #46, as of 09/30/21, revealed under ADL's/Restorative Care, the resident would tolerate left hand splint use in order to promote skin integrity and positioning throughout the day without distress. Under Special Needs, positioning devices included used left hand splint to maintain body alignment. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #46 for September 2021 revealed there was no order for the hand splint listed in the MAR or TAR and monitoring of the placement of the left hand splint was not documented. Observations on 09/27/21 at 8:37 A.M., 09/28/21 at 9:02 A.M., 09/28/21 at 1:07 P.M., and 09/29/21 at 3:15 P.M. of Resident #46 revealed the resident was laying in bed and did not have a splint on her left hand as ordered. Observation and Interview on 09/29/21 at 3:22 P.M. of Resident #46 with Director of Nursing (DON) #233 confirmed the resident was laying in bed and did not have a hand splint on her left hand. DON #233 confirmed the resident had an order for a left hand splint that should be in place during day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 FORM CMS-2567 (02/99) Previous Versions Obsolete shift. DON #233 searched the resident's room and found the hand splint in the resident's bathroom, laying on top of her broda chair. DON #233 placed the hand splint to the resident's left hand without incident. Review of the facility policy, Braces/Splints, updated 09/2018, stated the purpose of the policy was to maintain functional range of motion, decrease muscle contractures and provide support and alignment for weakened limbs through use of braces and splints, including hand splints. The policy stated verify medical practitioner's order. Observe body part on which the brace/splint was being applied and secure straps snugly, but not too tightly. Follow wearing schedule as outlined by rehabilitation therapist or medical practitioner. Event ID: Facility ID: 365611 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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. Based on medical record review, observation, interview, and facility policy and procedure, the facility failed to ensure fall interventions were in place and revised as needed. This affected two residents (Resident #25 and Resident #62) out of four residents reviewed for falls. Findings Include: 1. Review of the medical record for Resident #25 revealed an admission date of 05/17/11 with the diagnoses of falls, ataxia, lack of coordination and gait abnormalities. Review of Resident #25's Minimum Data Set (MDS) assessment, dated 07/16/21, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and she required extensive one assistance for bed mobility, dressing, toilet use and transfers, independence for locomotion via wheelchair, and supervision of one assist for personal hygiene. Review of Resident #25's fall investigations revealed the following: A. On 10/07/20 at 11:00 A.M. the resident was transferring from the bed to the wheelchair and lost balance. The resident was educated and encouraged to call for assistance when needed to prevent falls. B. On 03/01/21 at 10:30 A.M. the resident reported her legs gave out during a self transfer from the wheelchair to the commode. The new interventions was to re-educate the resident and she was encouraged to ask for help prior to the transfers. C. On 04/03/21 at 9:19 P.M. the resident was found in the bathroom sitting partially on the toilet and wheelchair. As the nurse came to assist she observed the resident slide slowly to the floor. The immediate intervention was to re-educate and reinforce the need to ask for help for all transfers. D. On 06/17/21 at 6:33 A.M. the resident was found sitting on her buttocks in front of the commode in the bathroom. She stated she was going to the bathroom and fell. She was not wearing proper foot wear, and she was reminded to wear proper footwear before attempting to transfer and voiced understanding. E. On 06/17/21 at 11:14 A.M. the resident was found on the floor in the bathroom with her back against the toilet seat. The new intervention was to re-educated the resident to call for assistance. F. On 07/04/21 at 4:35 A.M. the resident was observed kneeling next to the toilet seat. All fall interventions were reviewed and remained appropriate. The new intervention was to continue to educate and reinforce the resident to ask for help before transferring. The resident was able to ask for assistance but continued to self transfer. She was educated on risks versus benefits. G. On 07/24/21 at 5:47 A.M. the resident was noted sitting on the floor next to her wheelchair in the bathroom. The new intervention was to re-educate and encourage the resident to ask for assistance. Review of the care plan, dated 05/17/11, revealed the resident was at risk for falls due to poor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 balance related to Fredriech's Ataxia, not following recommendations of asking for assistance which she is non-compliant, and not wearing nonskid footwear with interventions to continue to encourage patient to call for help with transfers (dated 03/20/20), encourage patient to ensure footwear is on properly and tied if has shoestrings (dated 11/15/19), encourage resident to go to bed before she is so exhausted and reinforce to ask for help (dated 08/22/20), encourage to ask for assistance when transferring for showers (dated 08/12/19), encourage to wear proper foot wear (dated 02/15/19), non-skid strips to bathroom floor in front of shower and toilet (removed on 09/30/21), re-educate and reinforce to ask for help for all transfer (dated 07/26/21), re-educate/ encourage resident to ask for help prior to transfers (dated 03/01/21), reinforce and re-education for resident to call for assistance when wanting a shower (dated 10/08/20), reinforce wheelchair safety when transferring from bed to wheelchair such as locking brakes (09/10/19), remind resident to always call for assistance when transferring in the bathroom to the toilet or shower (dated 10/27/19), resident educated on safe transfer practices to avoid transferring self if legs are wobbly and weak, was advised to call for assistance (dated 01/31/20), resident refuses to ask for assistance with transfers and toileting and with showers regularly, risks and benefits discussed with family and resident (dated 09/11/17), resident was re-educated and encouraged to call for assistance and lock wheelchair (dated 11/05/20), staff to re-educate and encourage resident to call for help and wear proper footwear (dated 06/17/21). Interview on 09/30/21 at 9:53 A.M. with the Director of Nursing (DON) revealed the resident is alert and oriented and knows what she is doing and that they have exhausted all interventions for her falls so he felt the most they could do for her was to just continue to re-educate her after she falls. Interview and observation on 09/30/21 at 10:08 A.M. with Resident #25 revealed she cannot put her shoes on by herself and she hasn't been able to do so for approximately two years. She stated she puts the call light on and no one comes, and she cant transfer by herself. Resident #25's bathroom was observed without non-skid strips to the entrance of her shower. Interview on 09/30/21 at 10:34 A.M. with the DON revealed the non-skid strips in front of her shower shouldn't be an intervention anymore, but confirmed there were no non-skid strips currently in front of her shower. Review of the facility policy and procedure titled, Change in Condition or Falls Occurrence, dated 2011, revealed the care plan was revised as clinically indicated to meet the patients current needs. 2. Review of the medical record for Resident #62 revealed an initial admission date of 03/05/19 and a re-entry date of 08/20/21. Diagnosis included muscle weakness, dementia without behavioral disturbances, and abnormalities of gait and mobility. Review of the admission Minimum Data Set (MDS), 3.0 assessment, dated 08/27/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09 indicating a moderately impaired cognition for daily decisions making ability. No behaviors were noted at this time. The resident required extensive assistance from two staff members for bed mobility, transfers, locomotion on and off the unit, toileting needs, and personal hygiene. The resident was noted to have an impairment to his bilateral lower extremities and required the assistance of a wheelchair for locomotion. Resident #62 was noted to always be incontinent of bowel and bladder function. Review of the plan of care, dated 08/11/21, revealed Resident #62 was noted to be at risk for falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 due to weakness, impaired mobility, cognitive impairment, a history of falling, potential medication side effects, and decreased safety awareness. Interventions for this fall risk included, to place the residents bed in the lowest position while resident was in bed, and to have commonly used articles within easy reach. Review of Resident #62's nursing progress note dated 08/24/21 at 11:34 A.M. after a fall, revealed the resident had periods of hallucinations and was very confused at times, resident was unable to recall falling. Immediate intervention was to have the bed in lowest position to reduce injury if a fall occurred. Resident with cognitive deficits and history of encephalopathy. Resident #62's wife was well aware of the fall as was the Medical Director (MD). The note indicated the facility would follow up with care plan and update. Review of the fall assessment completed for Resident #62, dated 08/24/21, revealed the resident was at risk for falls due to the resident having periods of hallucinations and being very confused at times, and was unable to recall falling. Immediate intervention included to have the bed in lowest position to reduce injury if a fall occurred. Resident was with cognitive deficits, and a history of encephalopathy. Interview on 09/29/21 at 2:07 P.M. with Physical Therapy Assistant (PTA) #108 revealed Resident #62 required extensive assistance from two staff members for transfers. Resident #62 was currently receiving therapy services to assist with his gait and mobility. The difficult part for the resident was going from sitting to standing. Due to the resident having weak knees, when he tried to stand up, he had issues getting all of his weight forward and then would fall back down. PTA #108 confirmed Resident #62 was noted to have a fall not too long ago and was noted to be at risk for falls. Observation on 09/29/21 at 2:23 P.M. revealed Resident #62 resting quietly in bed with his eyes closed. The resident's bed was noted to be raised up in the air and not in the lowest position as per the interventions in the plan of care related to falls. Interview on 09/29/21 at 2:28 P.M. with Licensed Practical Nurse (LPN) #149 confirmed Resident #62's bed was not placed in the lowest position, per his plan of care, while he was laying in bed resting. Review of the facility policy titled, Falls Practice Guide Flowchart, undated, revealed under the Plan section revealed the facility world develop/revise initial or interdisciplinary care plan as applicable, and would initiate/update resident's information, worksheet, Kardex, and task list. The policy included implement ongoing fall preventions strategies. This deficiency substantiates Complaint Number OH00115404. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident had physician orders for the use of respiratory equipment referred to as a Continuous Positive Airway Pressure (CPAP) machine. This affected one resident (Resident #340) of two residents reviewed for respiratory care. Residents Affected - Few Findings include: Record review for Resident #340 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to obstructive sleep apnea, end stage renal disease, type two diabetes with unspecified diabetic retinopathy, and cognitive communication deficit. Review of Resident #340's comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired and required extensive assist with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review of resident #340's medical record revealed an inventory of personal effects form dated 09/15/21 indicating the resident was admitted to the facility with a CPAP machine. Review of Resident #340's September 2021 physicians' orders revealed the resident had no order for the CPAP machine. Review of the resident's care plan dated 09/15/21 revealed the resident has altered respiratory status/difficulty breathing related to obstructive sleep apnea. Interventions included, administer medications/puffers as ordered. Monitor for effectiveness and side effects. Monitor changes in condition, increased restlessness, anxiety, and air hunger. Observation and interview on 09/28/21 at 8:41 A.M. revealed Resident #340 was observed to have a CPAP machine located on the bedside nightstand. Resident #340 stated the CPAP machine is his personal machine he brought from home and he uses the CPAP every night while sleeping. Interview on 09/29/21 at 12:54 P.M., with the Director of Nursing (DON) also referred to as Registered Nurse (RN) #233, confirmed Resident #340 had no physician order for the use of the CPAP machine. Review of the facility policy titled, BIPAP/CPAP, revised 07/2017, revealed the procedure included verify medical practitioner's order for pressure, oxygen, and parameters for pulse oximetry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview, medical record review, and facility policy review, the facility failed to communicate and review dialysis labs for Resident #82. This affected one resident (Resident #82) of three residents reviewed for dialysis services. Residents Affected - Few Findings include: Review of the medical record for Resident #82 revealed an admission date of 08/23/13 and readmission date of 09/03/21 with diagnosis including dependent on renal dialysis, type two diabetes mellitus, pulmonary edema and congestive heart failure. The resident received renal dialysis three times per week on Tuesday, Thursday and Saturday at a local dialysis center. Review of the active plan of care for dialysis revealed interventions included obtain lab values and notify physician. Review of the Nurse Practitioner (NP) documentation on 07/09/21 revealed the resident refused to have labs drawn at the facility and the order was sent to dialysis to obtain labs there if possible. Resident #82 stated he would not have any blood drawn at the facility because he had blood work all the time at dialysis. Review of the lab results revealed Resident #82 had labs drawn at dialysis on the following dates; 07/15/21, 07/20/21, 08/12/21, 08/17/21, 09/09/21 and 09/14/21. Review of Resident #82's nursing progress notes from 07/10/21 through 09/29/21 revealed no evidence the facility received the lab results from dialysis, or notified the physician or the NP. Review of Resident #82's NP progress notes dated 07/23/21, 08/12/21 and 09/20/21 revealed there was no documentation related to lab results from labs drawn at dialysis on 07/15/21, 07/20/21, 08/12/21, 08/17/21, 09/09/21 and 09/12/21. Review of the communication forms titled dialysis center communication form the facility provided from 08/17/21 through 09/28/21 revealed no documentation related to Resident #82's labs or lab values. An interview on 09/29/21 at 4:40 P.M. with the Director of Nursing (DON) confirmed the facility NP had not addressed the labs for Resident #82 and there was no communication evidence between the facility and the dialysis center related to lab values. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on resident and staff interview, review of laboratory results, and record review, the facility failed to notify the physician or certified nurse practitioner (CNP) of new urinalysis test results for Resident #1. This affected one resident (Resident #1) of one resident reviewed for notification of change. Findings Include: Review of the medical record for Resident #1 revealed an original admission date of 01/21/21 and a readmission date on 09/16/21 with medical diagnoses including addisonian crisis, stage III chronic kidney disease, other specified sepsis, type II diabetes mellitus without complications, and urinary tract infection (UTI) with site not specified. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21, revealed Resident #1 had mildly impaired cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required extensive assistance from one to two staff to complete activities of daily living (ADLs), including toileting. The resident did not have a catheter and was always incontinent of both bowel and bladder. The resident was not on any toileting programs. Review of the Urinalysis lab with culture for Resident #1 revealed the sample was collected on 09/21/21 and the results were reported on 09/24/21. The lab report showed the resident's urine was amber in color and cloudy. The sample showed an A for abnormal readings for protein, leukocytes, bacteria, calcium oxalate crystal, amorphous, and mucous. The organism was identified as enterococcus faecium with a sensitivity to the antibiotic, Vancomycin. The total colony-forming unit (CFU) per milliliter (mL) was 70 to 99,000. Review of the nurse's notes for Resident #1 dated from 09/20/21 through 09/30/21 revealed on 09/20/21 at 1:36 P.M., Certified Nurse Practitioner (CNP) #500 visited Resident #1 for a medical stability visit with medication reconciliation and transfer of care. CNP #500 stated, the resident reports she thinks she has another UTI as she has burning when she urinates and this has been present for awhile. Diagnosis was noted to be nausea acute and dysuria acute. The plan indicated to obtain urine for urinalysis (UA) with culture and sensitivity (C & S) and may use Pyridium 100 milligrams (mg) with instructions to take one orally three times a day (TID) for three days after collection of urine. Review of Resident #1's nursing notes on 09/23/21 at 6:30 A.M., revealed Licensed Practical Nurse (LPN) #217 noted the resident continued on IV (intravenous) fluids, with no signs/symptoms of overload or infiltration noted. The UA was still pending. There were no additional nurse's notes which addressed when the UA results were reported to the facility or notification of the CNP or Physician that results had been received. Interview on 09/30/21 at 11:15 A.M. with Director of Nursing (DON) #233 confirmed neither the physician or the CNP were notified of the UA results for Resident #1. DON #233 confirmed the doctor or CNP should have been notified of the results. A facility policy related to notification of change was requested at the time of the survey. DON #233 stated the facility did not have a policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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. Based on medical record review and staff interview, the facility failed to ensure Resident #86's medical record reflected an accurate diagnosis for physician ordered medication. This affected one resident (Resident #86) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #86 revealed an admission date of 09/06/21. Diagnosis included age-related cognitive decline, abnormalities of gait and mobility, and disease of esophagus. Review of the admission Minimum Data Set (MDS) 3.0, assessment, dated 09/13/21, revealed the resident was noted with a ok long and short term memory and was independent for decisions regarding tasks of daily living. No behaviors were noted at this time. Resident #86 required extensive assistance from two staff members for bed mobility, and toilet use, and extensive assistance from one staff member for dressing, and personal hygiene. Resident #86 required the use of a indwelling catheter for bladder elimination and was continent of bowel elimination. Review of the physician orders for September 2021 for Resident #86 revealed a order for Famotidine (Pepcid, a antihistamine and antacid to treat acid reflux, heartburn and gastric ulcers), 20 milligram (mg) tablet, give one tablet, two times a day for autoimmune hepatitis. Review of the plan of care for Resident #86 revealed no care plan related to the diagnosis of Autoimmune Hepatitis. Interview on 09/29/21 at 2:40 P.M. with the Director of Nursing (DON) revealed Resident #86 did not actually have a diagnosis of Autoimmune Hepatitis. The DON claimed that when the residents information was put into her medical chart from the hospital, someone must have accidentally put that diagnosis in. The DON also confirmed that the medication Famotidine, would not have even been the appropriate medication to use for a patient with a Autoimmune Hepatitis diagnosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 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 Based on observation, interview, and record review, the facility failed to maintain infection control after a blood glucose check and during insulin administration. This affected one resident (Resident #80) out of two residents observed during medications administration for blood glucose checks and insulin administration. Residents Affected - Few Findings Include: Review of the record for Resident #80 revealed an admission date of 06/01/21 and the diagnoses of diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), anxiety, depression, insomnia, atrial fibrillation, opioid dependency, and chronic pain. The resident had no documented evidence of a transmissible disease. Review of Resident #80's Minimum Data Set (MDS) assessment. dated 09/08/21, revealed a Brief Interview of Mental Status (BIMS) of 15 indicating intact cognition and the resident required extensive assistance of one staff for bed mobility, personal hygiene, and toilet use, and supervision one assist for transfers and walking. Review of Resident #80's September 2021 physician orders revealed orders for Lispro insulin per blood glucose sliding scale with instructions to administer 4 units of insulin for a blood glucose between 201 and 250 before meals. Review of Resident #80's care plan, dated 06/02/21, revealed the resident had insulin dependent diabetes with interventions to administer medications per physician order and obtain glucometer readings and report abnormalities as ordered. Observation and interview 09/29/21 at 11:49 A.M. with Licensed Practical Nurse (LPN) #149 and Resident #80 revealed a blood glucose check. LPN #149 applied gloves, tested the blood with the strip (the reading was 241), she cleaned the blood off the finger with an alcohol wipe, walked out to the medication cart, put the items in the sharps container, unlocked the cart with her keys, retrieved the residents insulin, used the mouse and computer to figure out the sliding scale insulin amount, drew up the insulin (4 units), entered the residents room, administered the insulin, exited the room, unlocked the cart again with her keys, put the insulin back in the cart, opened the cleaning wipe and sanitized the glucometer, then removed the gloves she first applied before the blood glucose check. The above observation was confirmed with LPN #149 at 11:55 A.M. Review of the facility policy and procedure titled, Gloves: Non-Sterile/Sterile, dated December 2009, revealed the purpose of gloves was to protect staff when directly touching or handling items or surfaces soiled by bodily fluids containing blood, semen, vaginal secretions, mucous membranes or non-intact skin, and to protect the resident from infection. Review of the facility policy and procedure titled, Glucose Blood Monitoring, dated August 2014, revealed it was the facility policy to don gloves prior to blood sugar checks. After checking the blood sugar, staff were to disinfect the glucometer, then remove the gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 19 of 19