Health inspection·May 10, 2023

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 observation, resident interview, staff interview and policy reviews, the facility failed to ensure one resident (#20) of three residents reviewed for medication pass received continuous administration of all medications, the facility failed to ensure two (#10 and #20) of three residents reviewed for bathing services received routing bathing services, and the facility failed to ensure two (#10 and #40) of three residents reviewed for incontinence care received timely incontinence care. The total facility census was 93. Residents Affected - Some Findings Include: 1. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with the most recent hospitalization on 04/19/23 with a re-admission date to the facility of 04/23/23. Diagnoses include but are not limited to chronic obstructive pulmonary disease, adult failure to thrive, idiopathic peripheral autonomic neuropathy, osteoarthritis, weakness, anxiety, fibromyalgia, depression and bipolar disorder. Review of the resident most recent return anticipated minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident's short term memory was intact and she required modified independence with daily decision making. Resident had no delusion, hallucinations, or behaviors during the review period. Resident required extensive assist with bed mobility, transfers, and toileting, required limited assist with dressing and was independent with eating. Resident is coded as always continent of bladder and occasionally incontinent of bowel. Review of resident physician orders for 04/23 revealed the resident had orders for the following medications: Gabapentin 100 milligrams (mg) every eight hours daily for idiopathic peripheral autonomic neuropathy, give with 800 mg dated 01/19/22,and Gabapentin 800 mg every eight hours daily for idiopathic peripheral autonomic neuropathy, give with 100 mg dated 01/19/22. All medication should be crushed and put in applesauce for administration dated 04/08/23. Interview with Resident #20 on 05/08/23 at 10:38 A.M. revealed the facility discontinued her Gabapentin, the resident stated she has neuropathy real bad and has for a long time and the medication should not just be stopped. The resident stated she told staff about needing the medication and no one did anything. The resident stated she went to the hospital, and the facility now has her back on the Gabapentin and the dose is being tapered. Review of progress note dated 04/19/23 at 1:35 P.M. revealed the resident had requested to go to Page 1 of 13 365611 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the hospital related to her pain control and additionally stating she would be better off dead. The progress note verified the resident denied suicidal ideation's. The practitioner and family were informed and the resident was transferred to the hospital. Review of progress note dated 04/23/23 at 8:06 P.M. revealed the resident was re-admitted to the facility was alert and oriented times three, and was oriented to the room. Vital signs were obtained and were documented as stable: Temperature: 97.6 forehead, Blood Pressure: 118/62, Pulse: 76 beats per minute and regular, Respirations: 16 per minute, oxygen saturation was 98 % with oxygen via nasal cannula at 2 liters. Review of the after visit summary (AVS) for the hospital admission from 04/20/23 - 04/23/22 dated 04/23/23 at 8:55 A.M. revealed the resident had the following orders with additional instructions provided to pick up your medication at any pharmacy with your printed prescription provided. Gabapentin 100 every eight hours give with 800 mg and Gabapentin 800 mg every eight hours give with 100 mg. Review of the printed prescriptions provided for the Gabapentin 800 mg and 100 mg revealed the duration of use was written for five days on the paper prescription provided by the hospital physician. Review of the Medication Administration Record (MAR) for 04/23 it was revealed the Gabapentin was administered after re-admission starting on 04/24/23 with the second dose of the day and stopped on 04/28/23 after the third dose of the day and no other doses were documented as provided to the resident on 04/29/23 or 04/30/23. Review of the 05/23 MAR revealed the resident had no doses of Gabapentin provided 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, and 05/06/23. The Gabapentin was ordered on 05/07/23 and the medication was documented as provided starting with the 9:00 A.M. dose. Resident #20's medical record was silent to the resident expressing concerns with the Gabapentin not being provided to the resident from 04/28/23 through 05/06/23. Review of progress notes dated 05/07/23 at 1:37 A.M. revealed the resident had called emergency medical services on 05/06/23 to transport her to the hospital and the resident left the facility with emergency medical services on 05/06/23 at 8:40 P.M. The resident was documented to return to the facility on [DATE] with prescription for Gabapentin. Review of the AVS dated 05/06/23 at 9:17 P.M. regarding the resident's emergency room visit revealed the resident diagnosis in the emergency room was signs of drug withdrawal. The resident was ordered to receive Gabapentin 400 mg two capsules three times a day with a recommendation to wean off the medication by decreasing the dose by 100 mg every one to two weeks was provided The prescription provided to the resident had the duration of the Gabapentin as seven days. The resident returned to the facility from the emergency room on [DATE]. Interview with the Director of Nursing (DON) on 05/09/23 at approximately 8:00 A.M. it was confirmed Resident #20 had Gabapentin 900 mg every eight hours ordered for five days on return from the hospital on [DATE] and the resident received those doses. The DON confirmed the resident did not have Gabapentin from 04/29/23-05/07/23 when the resident returned from an emergency room visit with a new prescription for the medication. The DON stated the facility followed the orders provided. Interview with the Medical Director (MD) #530 on 05/09/23 revealed she is the provider who has seen Resident #20 during her stay at the facility. MD #530 stated the resident had gone to the hospital on [DATE] and had some respiratory issues addressed and was also seen by psychiatric services while 365611 Page 2 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in the hospital. MD #530 was asked if it was the plan to have Resident #20 weaned off Gabapentin and she stated from her perspective the Gabapentin was not scheduled to be weaned down and psychiatric services in the hospital did not recommend decreasing the medication either. MD #530 was asked if she was aware the resident medication was stopped after five days of use when she returned to the facility on [DATE]. MD #530 stated she was told the resident had only missed one dose of Gabapentin at the facility. MD #530 stated when a resident is released from the hospital any controlled substance, which would include Gabapentin even though it is not currently in a controlled drug class) will have a paper prescription for those medications and the duration of use will be for several days allowing the resident to not miss doses until the resident's provider has time to review the hospital stay so the resident's regular practitioner can reassess the medication and continue its use if necessary. MD #530 stated she was unaware the Gabapentin had stopped, MD #530 stated the Gabapentin should continue in the use of Resident #20 and no taper was being performed. Review of MD #530 progress note dated 04/24/23 revealed Resident #20 had chaotic pain which was controlled on the current regimen, and to continue Gabapentin. Review of MD #530 progress note dated 04/26/23 revealed the resident's medications were reviewed and included Gabapentin 800 mg by mouth every eight hours to be given with 100 mg for a total dose of 900 mg for five days. Review of MD #530 progress note dated 05/02/23 revealed the resident's medications were reviewed and included Gabapentin 800 mg by mouth every eight hours to be given with 100 mg for a total dose of 900 mg for five days. Interview with Resident #20 on 05/08/23 at 10:38 A.M. revealed she was not receiving routine bathing services and she had gone several weeks without bathing services prior to being admitted to the hospital. Review of Resident # 20's bathing services documentation revealed in the last 62 days the resident she had 8 showers , one bed bath and offered showers three times and refused. The resident bathing was documented as receiving a shower on 03/03/23, 03/20/23, 03/22/23, 04/01/23, 04/05/23, 04/12/23, 04/19/23, 04/26/23 and 05/06/23. Review of the shower schedule revealed Resident #20's shower was to be completed on the day shift on Tuesdays, Wednesdays, Fridays and Saturdays. Interview on 05/09/23 at 12:44 P.M. with Licensed Practical Nurse (LPN) revealed the facility provides bathing services to resident twice a week or per the residents preference more frequently. 2. Review of the medical record for Resident #10 revealed an admission date of 02/28/23. Diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, chronic respiratory failure with hypoxia, type two diabetes mellitus, heart disease, anemia, and depression. Review of the admission MDS assessment, dated 03/07/23, revealed the resident had intact cognition. The resident required one-person physical assist with activities of daily living and two person assist for bed mobility and transfers. Interview with Resident #10 on 05/08/23 at 2:18 P.M. revealed he had not had his incontinent brief changed since the night before. Resident #10 verified he uses a urinal to urinate but wears a brief 365611 Page 3 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm for fecal incontinence. The resident stated his STNA is at lunch and he had a bowel movement one and a half hours ago and had not been changed. Observation of Resident #10's incontinent brief with LPN #388 on 05/08/23 at 2:20 P.M. it was confirmed the resident had soft brown stool between his gluteus maximus folds. Residents Affected - Some Interview with Resident #10 on 05/10/23 at approximately 10:30 A.M. the resident stated he had not had a shower since he had been in the facility. During the interview the resident was observed to have a hospital gown on and the resident hair was sticking g up along the part on the right side of his head. Review of the shower schedule revealed Resident #10's shower was to be completed on the evening shift on Tuesdays, Wednesdays, Fridays and Saturdays. Review of Resident # 10's bathing services documentation revealed in the last 62 days the resident had two showers and four bed baths documented. The resident received a shower on 04/22/23 and 05/03/23 and the resident received a bed bath on 03/20/23, 03/23/23, 03/30/23 and 04/03/23. 3. Record review Resident # 40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to idiopathic normal pressure hydrocephalus, diabetes, vascular dementia, major depression, weakness and asthma. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident did not have delusions, hallucinations or behaviors coded. The resident was dependent on staff for transfers, required extensive assist of two staff for bed mobility, extensive assist for one for dressing, toileting, and personal hygiene and requires supervision for meals. The resident was coded as always incontinent of bowel and bladder. Observation of the resident's incontinent brief with LPN #388 on 05/08/23 at 2:06 P.M. it was revealed the resident's incontinent brief was fully saturated with urine from the front of the brief to the back of the brief. Resident #40 stated she had not been changed since this morning. Interview on 05/08/23 at 2:10 P.M. with STNA #330 who was the STNA assigned to care for Resident #40 confirmed the resident had not had incontinent care provided since 10:00 A.M. The STNA stated she had checked the resident around 12:00 P.M. but the resident was dry. The STNA stated she would provide care the Resident #40 . Interviews were conducted on 05/10/23 at 7:00 A.M. with State Tested Nursing Assistant (STNA) # 323 and #550 revealed they are not always able to get all of their task completed on their shift including bathing services, resident turning and incontinence care as they do not have enough time to complete the work the are assigned. The staff both stated they work together to complete as much as they can and they try to do all they are able. The staff stated if there is a call off the vacant shift is not filled and the management does not come out to help with the work load. The STNA's verified there is a schedule for bathing the residents in the facility and the schedule is twice weekly unless the resident has other preferences. Review of the policy titled admission Processes dated 06/08/22 revealed to verify physicians orders. 365611 Page 4 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of policy titled State Tested Nursing Assistant Bath/Shower Audit dated 06/08/22 revealed this facility will routinely monitor the skin condition of all residents during bathing activities which will be provided a minimum of twice a week. Procedure to include a master resident bath/shower schedule approved by the DON will list which shift each resident will be bathed a minimum of twice per week. This deficiency represents non-compliance investigated under Complaint Number OH00142574,OH00142568, and OH00141987. 365611 Page 5 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and facility staff interviews, the facility failed to provide staffing to meet the needs of four residents ( #10, #20, #40, and #80) of six residents reviewed. The facility census was 93. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 02/28/23. Diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, chronic respiratory failure with hypoxia, type two diabetes mellitus, heart disease, anemia, and depression. Review of the admission minimum data set (MDS) assessment, dated 03/07/23, revealed the resident had intact cognition. The resident required one-person physical assist with activities of daily living and two person assist for bed mobility and transfers. Interview with Resident #10 on 05/08/23 at 2:18 P.M. revealed he had not had his incontinent brief changed since the night before. Resident #10 verified he uses a urinal to urinate but wears a brief for fecal incontinence. The resident stated his State Tested Nursing Assistant (STNA) is at lunch and he had a bowel movement one and a half hours ago and had not been changed. Observation on 05/08/23 at 2:20 P.M. of Resident #10's incontinent brief with Licensed Practical Nurse (LPN) #388 confirmed the resident soft brown stool between his gluteus maximus folds. Interview with Resident #10 on 05/10/23 at approximately 10:30 A.M. revealed he had not had a shower since he had been in the facility. During the interview the resident was observed to have a hospital gown on and the resident hair was sticking up along the part on the right side of his head. Review of the shower schedule revealed Resident #10's shower was to be completed on the evening shift on Tuesdays, Wednesdays, Fridays and Saturdays. Review of Resident # 10's bathing services documentation revealed in the last 62 days the resident had two showers and four bed baths documented. The resident had a total of nine showers or bed baths when 32 showers or baths should have been provided. Resident #10 was documented to receive a shower on 04/22/23 and 05/03/23 and the resident received a bed bath on 03/20/23, 03/23/23, 03/30/23 and 04/03/23. Interviews on 05/10/23 at 7:00 A.M. with State Tested Nursing Assistant (STNA) # 323 and #550 revealed they are not always able to get all of their task completed on their shift including bathing services, resident turning and incontinence care as they do not have enough time to complete the work the are assigned. The staff both stated they work together to complete as much for the residents as they can but they do not always have the time to complete all their task. The STNA's stated if there is a call off the vacant shift is not filled with another worker and they have to pick up the extra work. The STNA's verified there is a schedule for bathing the residents in the facility and the schedule is twice weekly unless the resident has other preferences. 2. Record review Resident # 20's medical record revealed the resident was admitted to the facility 365611 Page 6 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on [DATE] with the most recent hospitalization on 04/19/23 and a re-admission on [DATE]. Diagnoses include but are not limited to chronic obstructive pulmonary disease, adult failure to thrive, idiopathic peripheral autonomic neuropathy, osteoarthritis, weakness, anxiety, fibromyalgia, depression and bipolar disorder. Review of the resident most recent return anticipated MDS 3.0 assessment dated [DATE] revealed the resident's short term memory was intact and she required modified independence with daily decision making. Resident had no delusions, hallucinations, or behaviors during the review period. Resident required extensive assist with bed mobility, transfers, and toileting, required limited assist with dressing and was independent with eating. Resident is coded as always continent of bladder and occasionally incontinent of bowel. Interview with Resident #20 on 05/08/23 at 10:38 A.M. the resident stated she was not receiving routine bathing services and she had gone several weeks without bathing services being provided to her recently. Review of the shower schedule revealed Resident #20's shower was to be completed on the day shift on Tuesdays, Wednesdays, Fridays and Saturdays. Review of Resident # 20's bathing services documentation revealed in the last 62 days the resident she had 8 showers, one bed bath and the resident refused three showers. The resident had a total of nine showers or bed baths when 24 showers or baths should have been provided. Resident #10 was documented as having either a shower or a bed bath on 03/03/23, 03/20/23, 03/22/23, 04/01/23, 04/05/23, 04/12/23, 04/19/23, 04/26/23 and 05/06/23. 3. Record review Resident # 40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to idiopathic normal pressure hydrocephalus, diabetes, vascular dementia, major depression, weakness and asthma. Review of the most recent quarterly MDS 3.0 assessment dated [DATE] revealed the resident did not have delusions, hallucinations or behaviors coded. The resident was dependent on staff for transfers, required extensive assist of two staff for bed mobility, extensive assist for one for dressing, toileting, and personal hygiene and requires supervision for meals. The resident was coded as always incontinent of bowel and bladder. Observation of the resident's incontinent brief with Licensed Practical Nurse (LPN) #388 on 05/08/23 at 2:06 P.M. it was revealed the resident's attend was fully saturated with urine from the front of the brief to the back of the brief. Resident # 40 stated she had not been changed since this morning. Interview on 05/08/23 at 2:10 P.M. with STNA #330 who was the STNA assigned to care for Resident #40 on 05/08/23 confirmed the resident had not had incontinent care provided since 10:00 A.M. The STNA stated she had checked the resident around 12:00 P.M. but the resident was dry. The STNA stated she would provide incontinent care to the Resident #40 . 4. Observation of medication pass on 05/08/23 revealed Resident #80's 9:00 A.M. medications were provided to the resident at 11:00 A.M. by LPN #362. The medications the resident received two hours after the scheduled administration time were: 365611 Page 7 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 Amlodipine 10 milligrams (mg) (calcium channel blocker) by mouth daily scheduled at 9:00 A.M., Level of Harm - Minimal harm or potential for actual harm Aspirin 81 mg (blood thinner) by mouth daily scheduled at 9:00 A.M., Cinacalcet 60 mg (calcium reducer) by mouth daily scheduled at 9:00 A.M., Residents Affected - Some Gabapentin 300 mg (antidepressant ) by mouth daily scheduled at 9:00 A.M. Zoloft 50 mg (antidepressant) by mouth daily scheduled at 9:00 A. M. Buspar 10 mg (antidepressant) by mouth twice daily at 9:00 A.M. and 9:00 P.M. Eliquis 5 mg (anticoagulant) by mouth twice daily at 9:00 A.M. and 9:00 P.M. and Nystatin 100,000/ml (antifungal) give 5 ml swish and swallow daily at 9:00 A.M. Interview on 05/08/23 at 11:00 A.M. with LPN #362 verified the medications are being provided late to the resident because she cannot pass all medications to the 36 residents on her assignment within the scheduled medication time. The LPN stated due to the volume of her work load she is not able to complete all task assigned to her including medication pass. She stated she will finish morning medication pass and it will be time to start the afternoon medication pass. Interview with LPN #305 on 05/09/23 at 7:34 A.M. revealed the nurse is unable to pass medications to 36 residents on her assignment within the scheduled medication pass times. Interview with Registered Nurse (RN) # 326 on 05/09/23 at 7:56 A.M. it was revealed she does not have enough time to complete her duties during her scheduled shift. The RN stated she usually has 40 residents on the 300 and part of 400 hallway and she cannot provide medications to 40 residents and have them provided in the correct time frame. The RN stated the facility previously had three nurses for the 300 and 400 hallways however in the last month the number of nurses has been cut frequently to two, leaving two staff to care for both hallways. The RN was asked if she is able to manage the STNA's on her hallway to ensure they residents are receiving their required care, bathing, turning, and feeding etc. and the RN responded we are all adults and the STNA's know what their duties are. The RN stated she does not know if the residents are being provided incontinent care every two hours as per standard, or if the residents are receiving their scheduled showers as she is not the staff providing the care. The RN stated she often has to stay past her shift time to complete the work required of her. Review of the resident census revealed there were 72 residents currently residing on the 300 and 400 hallway. During separate interviews with Resident #10, #20, and #40 all residents stated the do not receive their medication at the time it is ordered. Review of policy titled State Tested Nursing Assistant Bath/Shower Audit dated 06/08/22 revealed this facility will routinely monitor the skin condition of all residents during bathing activities which will be provided a minimum of twice a week. The procedure included a master resident bath/shower schedule approved by the Director of Nursing (DON) will list which shift each resident will be 365611 Page 8 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0725 bathed a minimum of twice per week. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00142126 and 141987. Residents Affected - Some 365611 Page 9 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and facility staff interview, the facility failed to maintain a medication error rate below five percent. This affected two residents (#80 and #110) of three residents reviewed for medication pass. The facility census was 93. Residents Affected - Few Findings Include: Observation of medication pass on 05/08/23 and 05/09/23 revealed a total of 28 opportunities were observed with 10 errors for a total medication error rate of 35%. 1. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to metabolic encephalopathy, weakness, type two diabetes, falls, anxiety disorder, rheumatoid arthritis, hypertension and dementia. Review of the five-day Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact, had no behaviors and required extensive assist with all activities of daily living with the exception of eating which she required supervision. Review of resident medications revealed the resident had ordered to receive at 9:00 A.M. daily the following medications: Amlodipine 10 milligrams (mg) (calcium channel blocker) by mouth Aspirin 81 mg (blood thinner) by mouth daily Cinacalcet 60 mg (calcium reducer) by mouth Gabapentin 300 mg (antidepressant) by mouth Zoloft 50 mg (antidepressant) by mouth. Buspar 10 mg (antidepressant) by mouth Eliquis 5 mg (anticoagulant) by mouth and Nystatin 100,000/milliliter(ml) (antifungal) give 5 ml swish and swallow. Resident #80 had orders for Memantine 5 mg (cognitive enhancer) daily by mouth upon rising. During the observation of Resident #80 receiving her medications on 05/08/23 at 11:00 A.M. Licensed Practical Nurse (LPN) # 362 was observed to obtain, prepare, and take the following medication in to Resident #80. Amlodipine 10 mg (calcium channel blocker) by mouth Aspirin 81 mg (blood thinner) by mouth 365611 Page 10 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0759 Cinacalcet 60 mg (calcium reducer) by mouth Level of Harm - Minimal harm or potential for actual harm Gabapentin 300 mg (anticonvulsant and nerve pain) by mouth Zoloft 50 mg (antidepressant) by mouth. Residents Affected - Few Buspar 10 mg (antidepressant) by mouth Eliquis 5 mg (anticoagulant) by mouth and Nystatin 100,000/ml (antifungal) give 10 ml swish and swallow. Interview with LPN # 362 on 05/08/23 at 11:59 A.M. it was verified the Memantine 5 mg was not provided to Resident #80 and Nystatin 100,000 mg/ml 10 ml were provided to the resident and not the 5 ml ordered, and the medications were provided two hours after the scheduled administration time. 2. Review of Resident #110's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of gout, chronic kidney disease stage III, obesity type two diabetes and weakness. Review of the admission MDS 3.0 assessment dated [DATE] revealed the resident is cognitively intact, had no behaviors was dependent on staff for transfers and required extensive assist for bed mobility, dressing, toileting and personal hygiene. The resident was coded as requiring supervision for eating. Review of resident medications revealed the resident had ordered to receive at 9:00 A.M. daily the following medications: Allopurinol 100 mg (anti gout) by mouth Gabapentin 800 mg (anticonvulsant and nerve pain) by mouth Lisinopril 20 mg (antihypertensive) by mouth Metformin 500 mg (antidiabetic)two tablets by mouth Methocarbamol 750 (skeletal muscle relaxant) by mouth Vitamin D3 (supplement) 1000 by mouth Indomethacin 50 mg (non steroidal anti inflammatory) by mouth During the observation of Resident #110 receiving his medications on 05/09/23 at 7:46 A.M. Registered Nurse (RN) # 326 was observed to obtain, prepare, and take the following medication in to Resident #110 Allopurinol 100 mg (anti gout) by mouth Gabapentin 800 mg (anticonvulsant and nerve pain) by mouth 365611 Page 11 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0759 Lisinopril 20 mg (antihypertensive) by mouth Level of Harm - Minimal harm or potential for actual harm Metformin 500 mg (antidiabetic) two tablets by mouth Methocarbamol 750 (skeletal muscle relaxant) by mouth Residents Affected - Few Vitamin D3 (supplement)1000 by mouth When RN # 326 provided Resident #110 with his medications the resident stated my green little pill is not in the cup. The nurse stated she would need to go and get the ordered medication. RN #326 was observed to watch Resident #110 to take the medications provided and then return to the medication cart and obtain the missing medication which was Indomethacin 50 mg and provide the medication to the resident. Interview with RN #326 on 05/09/23 at 7:59 A.M. it was confirmed the Indomethacin was not included in the medications she had prepared and gave to Resident #110. RN #326 then provided the missing medication to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00142568 and OH00142126. 365611 Page 12 of 13 365611 05/10/2023 Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interviews, and review of facilities improvement plans, the facility failed to ensure a safe, functional , sanitary and comfortable environment. This had the potential to affect six residents (Resident #10,#170,#150,#800,#805, and #810) out of 93 residents residing in the facility. Findings include: Observation on 05/08/23 at 11:00 A.M. of Resident #10's ceiling revealed a 24 x 24 area of paint peeling with dry wall exposed and above Resident #170's bed revealed a 12 x 12 circle of paint peeling from the ceiling with dry wall exposed. This was verified by Licensed Practical Nurse (LPN) #362 at time of observation. Observation on 05/09/23 from 1:45 P.M. to 2:15 P.M. revealed the ceiling above Resident #150's bed had peeling paint from the ceiling . Resident #800 has wallpaper pulling away from the wall behind his bed , with exposed crumbled dry wall and the base board is coming away from the wall. This was verified by Housekeeper # 379 at time of observations. Observation on 05/09/23 and 05/10/23 at 3:00 P.M. of Resident #805 and #810's room revealed the bathroom floor to be a dull like grey color resembling dirt , the base of the shower entrance was cracked. Dirty clothes and linens were in a transparent plastic bag by the sink on the floor on top of a wheelchair footrest. On the commode tank there were two urine gradual measuring cups that were air drying on a paper towel . They were not in a plastic bag. The bathroom had a strong foul odor of urine. This was verified by Housekeeper # 379 at time of observation. Review of projected improvement plans provided by the Administrator from the facility owners did not convey any improvement plans for resident rooms or bathrooms. This deficiency represents non-compliance investigated under Complaint Number OH00142538. 365611 Page 13 of 13