Health inspection·October 10, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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, and interview, the facility failed to ensure one resident (#28) had a physician's order and was assessed for self-administration of medication. This affected one (Resident #28) of three residents observed for medication administration. The facility census was 92. Residents Affected - Few Findings Include: Review of the medical record for Resident #28 revealed an initial admission date of 03/04/23 with the latest readmission of 07/14/23 with diagnoses including diabetes mellitus, cardiomyopathy, congestive heart failure, hyperlipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, hypertension, end stage renal disease, dependence on hemodialysis and gout. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairment. Review of the monthly physician orders for October 2023 identified orders dated 07/18/23 Fluticasone Propionate nasal suspension 50 micrograms (mcg) with the special instructions to spray two sprays in each nostril daily for allergies. Review of the medical record revealed no self-administration medication assessment to self- administer the Fluticasone Propionate. Review of the resident's plan of care revealed no care plan addressing the resident self-administration of the medications Fluticasone Propionate. On 10/03/23 at 8:54 A.M., observation of Registered Nurse (RN) #209 revealed the RN prepared Resident #28's morning medication. The RN revealed the resident kept the medication Fluticasone Propionate at bedside and she would ask if he took the medication for the morning. The RN delivered the medication to Resident #28 and asked the resident if he took the medication Fluticasone Propionate. The resident stated, I already used the spray. On 10/03/23 at 1:43 P.M., interview with Director of Nursing (DON) #225 verified the resident had no self administration assessment, physician order or care plan to self-administer the medication Fluticasone Propionate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 2 of 47 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 10/10/2023 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and facility policy review, the facility failed to ensure one resident (#1) was bathed per their preference and one resident (#79) was dressed per their preference. This affected two ( Resident #1 and #79) of five residents reviewed for choices. The facility census was 92. Findings Include: 1. Review of the medial record for Resident #1 revealed an initial admission date of 04/27/23 with diagnoses including pneumonia, metabolic encephalopathy, dysarthria, dementia, depression, cerebral infarction, osteoarthritis, dysphagia, generalized muscle weakness and repeated falls. Review of the plan of care dated 07/13/23 revealed the resident had a self-care performance deficit related to CVA and dementia. Interventions included staff to assist with activities of daily living (ADL) as needed, monitor for fatigue and provide rest periods as needed and reassess quarterly and as needed. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The resident required limited assistance of one staff with transfers, ambulation and was dependent on one staff for bathing. Review of the facility shower schedule revealed the resident was scheduled for showers every Monday and Thursday on the evening shift. Review of the recreation admission assessment dated [DATE] revealed it was very important to the resident to choose what type of bathing she received. Further review revealed the resident preferred showers. Review of the resident's shower documentation for July 2023 revealed the resident received a bedbath on 07/06/23, 07/13/23, and on 07/20/23 instead of a shower as preferred. Review of the resident's shower documentation for August 2023 revealed the resident received a bedbath on 08/03/23, 08/14/23, 08/24/23, and 08/31/23 instead of a shower as preferred. Review of the resident's shower documentation for September 2023 revealed the resident received a bedbath on 09/07/23 instead of a shower as preferred. Review of the resident's shower documentation for October 2023 revealed the resident received a bedbath on 10/02/23 instead of a shower as preferred. On 10/04/23 at 4:02 P.M., interview with the Director of Nursing (DON) #225 verified the Resident #1 had not received bathing as preferred. 2. Review of the medical record for the Resident #79 revealed an initial admission date of 01/24/23 with several trips out to the hospital. Diagnoses included encephalopathy, fracture of the upper end right humerus, fracture of the third metacarpal left hand, fracture of the fifth metacarpal left hand, muscle weakness, liver cirrhosis and seizures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 3 of 47 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 10/10/2023 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact and required extensive assistance of one staff member for bed mobility, transfers, and limited to extensive assist of one person (physical assist) for ambulation and activities of daily living. Review of the plan of care dated 08/28/23 revealed Resident #79 had an activity of daily living self-care performance deficit with interventions including staff to anticipate needs on a daily basis and staff to assist with completion of activities of daily living on a daily basis so needs are met. Interview and observation on 10/02/23 at 2:30 P.M. of Resident #79 revealed resident was wearing a medical gown and was laying in bed. Resident revealed she preferred to wear regular clothes and that staff had not offered to get her dressed. Numerous observations on 10/02/23 from 9:00 A.M. to 6:00 P.M. revealed Resident #79 was wearing a medical gown for the entirety of the day. Numerous observations on 10/03/23 from 8:00 A.M. to 7:15 P.M. revealed Resident #79 was wearing a hospital gown for the entirety of the day. Interview and observation on 10/04/23 at 8:50 A.M. with LPN #606 confirmed several residents on the hall were wearing gowns. She revealed residents should be offered assistance to get dressed in regular clothing and if they refuse care, the aides should inform the nurse. LPN revealed she had not heard any concerns related to Resident #79 refusing care or to get dressed. Interview and observation on 10/04/23 at 8:56 A.M. with State Tested Nursing Aide (STNA) #263 revealed Resident #79 refused to get dressed most days and revealed she had not yet offered to assist resident in getting dressed for the day. STNA revealed resident did not have much clothing to use so staff mainly swap out medical gowns when changing her clothes, but confirmed at the time of the observation had clothes hanging up in the closet, but did not have many options to pick from. STNA revealed she would offer resident assistance to get dressed after she got another resident ready for therapy. Observation and interview on 10/04/23 at 1:35 P.M. with STNA #263 revealed resident #79 was dressed in clothes and wearing a pink shirt and not a medical gown. STNA revealed resident was agreeable and staff assisted her in getting her dressed. Review of facility policy titled Resident rights and facility responsibilities, undated, revealed the facility would abide by all resident rights. The policy revealed the resident had the right to be treated at all times with courtesy, respect, dignity and individuality. The policy also revealed residents should receive appropriate care and treatment and should receive appropriate medical treatment, nursing care, and ancillary services. The policy revealed the facility should respond to requests promptly and have clothes changed as the need arises and ensure comfort and sanitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 4 of 47 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 10/10/2023 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, record review, and interview, the facility failed to ensure two resident's (#5 and #52) room was free of a persistent odor of urine. This affected two (Resident #5 and #52) of seven residents reviewed for environmental concerns. The facility census was 92. Findings Included: 1. On 10/02/23 at 11:12 A.M., observation of Resident #52 revealed the resident had an indwelling urinary catheter. The resident's room had a strong odor of urine. Interview with Resident #52 revealed she could smell the odor of urine in her room and the smell bothered her. Resident #52 revealed she requested the indwelling urinary catheter collection bag be changed but to date had not been changed. On 10/02/23 at 3:35 P.M., observation of Resident #52's room revealed the room continued to have a strong odor of urine. Interview with State Tested Nursing Assistant (STNA) #265 verified at the time of the observation the resident's room had a persistent strong odor of urine. 2. On 10/02/23 at 3:40 P.M., observation of Resident #5's room revealed the room had a strong persistent odor of urine. STNA #26 verified Resident #5's room had a persistent strong odor of urine at the time of the observation. This deficiency represents non-compliance investigated under Complaint Number OH00146341. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 5 of 47 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 10/10/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to report a suspected crime to local law enforcement. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Residents Affected - Few Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing to support her debit card being taken without her permission. There was no documentation to support law enforcement was notified nor the facility giving Resident #16 the opportunity to speak with law enforcement about her debit card that was taken. Review of Resident #92 progress notes, dated 08/04/23, revealed he had left the faciity on a leave of absence (LOA) and Resident #16 gave him, her debit card to purchase some items at the grocery store. When he did not return to the facility, the debit card was not returned as well. There was no documentation to support Resident #16 allowed Resident #92 to keep her debit card outside of purchasing the grocery items she had requested. Review of police report regarding Resident #92 LOA and illegal substance finding within the facility, dated 08/04/23 at 3:53 P.M., revealed there was no report to law enforcement at that time of Resident #16 debit card being taken for longer than allowed. Interview with Resident #16 on 10/04/23 at 9:04 A.M. and 5:40 P.M. confirmed she was never given the opportunity to speak with law enforcement about her debit card that was taken by Resident #92 for a longer period of time than she allowed, and that it was never returned to her. She stated she would have liked to speak with law enforcement about it. Interview with Administrator on 10/05/23 at 2:25 P.M. confirmed there was no documentation to support Resident #16 had the opportunity to speak with law enforcement nor a report of the debit card that was taken by Resident #92. Review of facility Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated 10/24/22, revealed the definition of misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. If facility suspects that a crime has been committed, it will report that suspicion to law (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 6 of 47 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 10/10/2023 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 0607 enforcement. For suspected crimes that do not involve serious bodily injury, law enforcement must be notified within 24 hours. 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 7 of 47 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 10/10/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to report alleged incidents in a timely manner. This affected two (Residents #16 and Resident #45) of five resident incidents reviewed. The census was 92. Findings Include: 1. Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing to support her debit card being taken without her permission. Review of Resident #92 progress notes, dated 08/04/23, revealed he had left the faciity on a leave of absence (LOA) and Resident #16 gave him, her debit card to purchase some items at the grocery store. When he did not return to the facility, the debit card was not returned as well. There was no documentation to support Resident #16 allowed Resident #92 to keep her debit card outside of purchasing the grocery items she had requested. Review of facility Self Reported Incident (SRI) tracking system confirmed this allegation of misappropriation was not reported at all. Interview with Administrator on 10/05/23 at 2:25 P.M. confirmed they did not complete an SRI, nor report the allegation of misappropriation in a timely manner. 2. Review of the medical record for Resident #45 revealed an admission date on 08/14/23. Medical diagnoses included displaced fracture of the posterior wall of right acetabulum, fracture of right acetabulum, fracture of upper end of left humerus, subluxation of right hip, type II diabetes mellitus with chronic kidney disease, mild intellectual disabilities, and difficulty in walking. Review of the Medicare Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #45 requested extensive assistance from two staff for bed mobility and total dependence from two staff to complete transfers. Resident #45 required extensive assistance to total dependence from one to two staff to complete all other Activities of Daily Living (ADLs). Resident #45 had functional limitations with impairments on one side of both the upper extremity and lower extremity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 8 of 47 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 10/10/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of physician orders dated October 2023 revealed Resident #45 had the following orders: non weight bearing to left arm and toe touch weight bearing to right leg effective 08/14/23. Review of physical therapy and occupational therapy orders revealed both therapies were discontinued effective 08/31/23 due to Resident #45 reaching maximum potential until weight bearing status was changed. Review of the progress notes revealed on 10/02/23 at 10:21 A.M., Registered Nurse (RN) #209 noted Resident #45 was alert and had left the faciity on a Leave of Absence (LOA) for an appointment. On 10/02/23 at 10:51 A.M., RN #209 was notified by Transportation ([NAME]) #225 she was transporting Resident #45 to his appointment. [NAME] #225 looked in the mirror while on the freeway and observed Resident #45 sliding out of his wheelchair. [NAME] #225 pulled over and called 9-1-1. Resident #45 was complaining of knee pain. On 10/02/23 at 3:08 P.M., Resident #45 was taken to a local hospital and admitted . Review of the instructions to properly secure a resident in a wheelchair in the transport van revealed lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels, or frame. Interview on 10/03/23 at 3:15 P.M. with [NAME] #225 confirmed she was transporting Resident #45 to an outside appointment on 10/02/23 when [NAME] #225 noticed Resident #45 was sliding out of his wheelchair during the transport. [NAME] #225 stated there was a hoyer lift pad underneath of Resident #45 in the wheelchair. Resident #45 had been complaining of knee pain prior to leaving for the appointment. [NAME] #225 stated Resident #45 had not been up in his wheelchair since he arrived at the facility but staff indicated Resident #45 was safe to be travel by wheelchair. [NAME] #225 stated by the time she was able to safely pull over, Resident #45 had slid completely out of his wheelchair and was sitting on the floor in front of his wheelchair with both legs extended straight out. [NAME] #225 stated there were four brakes to keep the wheelchair locked into place and a seatbelt that was pulled down from the ceiling and across the resident's wheelchair before locking into place. [NAME] #225 stated the seatbelt went over the wheelchair arms before it was locked into place. [NAME] #225 confirmed there was a gap between the resident and seatbelt when it was locked. Interview on 10/03/23 at 5:15 P.M. with the Administrator confirmed when strapping a resident into the transport van, the seatbelt should be under the wheelchair arms so it fits snug against the resident, like a regular seatbelt in a car. The Administrator confirmed the incident had not been reported as a possible allegation of neglect. The Administrator stated he was not aware [NAME] #225 had put the seatbelt over the wheelchair arms instead of under them. Interview on 10/04/23 at 1:00 P.M. with Maintenance Director (MD) #260 revealed the facility received the transport van in April 2023. MD #260 stated the facility recently started to complete the training with all the staff that drive the van. When securing a resident the van, they should follow the instructions that staff are trained on. The instructions are also located in the van for reference. They will use four points of restraints to the wheelchair and then they will use a shoulder and lap strap to secure the resident. The lap strap will be put underneath or as close to the resident's body as possible, to secure them to the chair. MD #260 confirmed he did not complete any retraining with [NAME] #225 following the incident and did not assess the van or the straps to determine if there was a problem with any of the equipment. Interview on 10/04/23 at 4:38 P.M. with the Administrator confirmed no further progress on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 9 of 47 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 10/10/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few investigation had been made due to the annual survey being in progress. The Administrator again confirmed the incident had not been reported as a possible allegation of neglect. Interview on 10/04/23 at 4:52 P.M. with RN #209 revealed Resident #45 was mostly bed bound since his admission to the facility. RN #209 stated she had observed him up in a broda wheelchair one time with therapy since his admission in August 2023. RN #209 confirmed she was working on 10/02/23 when Resident #45 was transported to an outside appointment. RN #209 confirmed Resident #45 left the facility in a standard wheelchair. RN #209 confirmed Resident #45 was not assessed for safety to travel in a wheelchair prior to leaving for his appointment on 10/02/23. Interview on 10/04/23 at 4:59 P.M. with the Director of Nursing (DON) revealed she was not familiar with any certain criteria that should be met in order for a resident to be safe to be transported by wheelchair. The DON stated, to me, if a resident can sit in a wheelchair, they are capable of being transported by wheelchair. The DON confirmed Resident #45 had not been assessed for safety prior to being transported to an outside appointment by wheelchair. Interview via telephone on 10/04/23 at 5:21 P.M. with the facility's contracted transportation company revealed in order for a resident to be able to be transported by wheelchair safely, the resident needed to be able to stand and pivot or self-transfer, sit upright, and be able to help themselves push back if started sliding out of the wheelchair. If a resident required maximum assistance, was non-weight bearing, or bed bound, the resident should be transported by a stretcher. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, reviewed 10/24/22, revealed the policy stated, an alleged violation was a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect was the failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Furthermore, all other allegations involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown source will be reported to Ohio Department of Health (ODH) immediately, but in no event later than 24 hours from the time the incident /allegation was made known to the staff member. The definition of misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. Notification to the state department of health will be made by using the online enhanced information and dissemination and collection (EIDC) system. Facility will submit an online SRI form in accordance with the state department of health's then-current instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 10 of 47 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 10/10/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to investigate an allegation of misappropriation. This affected one (Residents #16) of five resident incidents reviewed. The census was 92. Residents Affected - Few Findings Include: Resident #16 was admitted to the facility on [DATE]. Her diagnoses were polyneuropathy, other signs and symptoms involving the musculoskeletal system, other idiopathic peripheral autonomic neuropathy, neuralgia and neuritis, unspecified protein calorie malnutrition, major depressive disorder, alcohol abuse, morbid obesity, hypertension, other chronic pain, pain in lower left leg, pain in lower right leg, unspecified intellectual disabilities, vitamin D deficiency, muscle weakness, and long term use of opiate analgesic. Review of her Minimum Data Set (MDS) assessment, dated 07/16/23, revealed she was cognitively intact. Review of Resident #16 medical records, which included progress notes, care plans, and investigation reports, revealed nothing to support her debit card being taken without her permission. There was no documentation to support law enforcement was notified nor the facility giving Resident #16 the opportunity to speak with law enforcement about her debit card that was taken. Review of Resident #92 progress notes, dated 08/04/23, revealed he had left the faciity on a leave of absence (LOA) and Resident #16 gave him, her debit card to purchase some items at the grocery store. When he did not return to the facility, the debit card was not returned as well. There was no documentation to support Resident #16 allowed Resident #92 to keep her debit card outside of purchasing the grocery items she had requested. Interview with Resident #16 on 10/04/23 at 9:04 A.M. and 5:40 P.M. confirmed she was never given the opportunity to speak with law enforcement about her debit card that was taken by Resident #92 for a longer period of time than she allowed, and that it was never returned to her. She stated she would have liked to speak with law enforcement about it. She also confirmed she was not assisted by the facility to help close her account. She was not sure if any type of investigation occurred about the incident. Interview with Administrator on 10/05/23 at 2:25 P.M. confirmed there was no documentation to support Resident #16 had the opportunity to speak with law enforcement nor a report of the debit card that was taken by Resident #92. He confirmed the only document they have regarding an investigation with the missing debit card was a statement taken from the social worker; they have no police report, no interview statements, and no financial statements from Resident #16 to determine if the debit card was even used. Review of facility Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property policy, dated 10/24/22, revealed the definition of misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 11 of 47 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 10/10/2023 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 0610 Level of Harm - Minimal harm or potential for actual harm The investigation must be completed within five working days. The person investigating the incident should generally take the following actions: interview the resident, the accused, and all witnesses. Interview other healthcare professionals as appropriate. Review all relevant medical reports/records as applicable. Evidence of the investigation should be documented in accordance with quality assurance protocols. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 12 of 47 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 10/10/2023 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to perform an accurate discharge assessment. This affected one (Resident #92) of three resident discharges reviewed. The census was 92. Residents Affected - Few Findings Include: Resident #92 was admitted to the facility on [DATE]. His diagnoses were diverticulitis, type II diabetes, other chronic pain, hyperlipidemia, hypertension, arthrogryposis multiplex congenital, cognitive communication deficit, muscle weakness, depression, and vitamin D deficiency. Review of his minimum data set (MDS) assessment, dated 06/29/23, revealed he was cognitively intact. Review of Resident #92 MDS assessment section A, dated 08/03/23, revealed the facility documented he was discharged to a hospital. Review of Resident #92 progress notes, dated 08/04/23, revealed Resident #92 left the faciity on a leave of absence. It was documented that he had not returned to the facility in more than 24 hours, so he was discharged . There was no documentation to support at the time of discharge that Resident #92 had been admitted to the hospital. Review of facility Sign Out log, dated 08/03/23, revealed Resident #92 signed out of the facility on 08/03/23 at 9:10. Based on Resident #92 Medication Administration Records (MAR), dated 08/03/23, revealed he missed his 9:00 A.M. medication administration, so it is accurately assumed that he left the facility at 9:10 A.M. Interview with Social Worker #400 on 10/03/23 at 2:49 P.M. revealed they were told Resident #92 was admitted to the hospital after he went LOA. She is not sure when he was admitted to the hospital, or what time he left the faciity on [DATE]. Interview with Regional Director #603 on 10/04/23 at 1:00 P.M. confirmed documentation in Resident #92 medical record supported he left the faciity on [DATE] at 9:10 A.M. Interview with MDS Nurse #280 on 10/05/23 at 9:07 A.M. confirmed the date which the MDS assessment was completed (08/03/23) should be reflective of the date which the resident discharged from the hospital. She confirmed the medical records for Resident #92 would reflect that he discharged the facility on 08/03/23 against medical advice (AMA). There was no documentation to support he had been admitted to the hospital; she can't remember where she got the information about him being in the hospital to indicate on his discharge MDS that he went to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 13 of 47 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 10/10/2023 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy review, the facility failed to revise comprehensive care plans for two residents (Residents #45 and #83). This affected two residents (Residents #45 and #83) out of 24 reviewed for comprehensive care plans. The facility census was 92. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date on 08/14/23. Medical diagnoses included displaced fracture of the posterior wall of right acetabulum, fracture of right acetabulum, fracture of upper end of left humerus, subluxation of right hip, type II diabetes mellitus with chronic kidney disease, mild intellectual disabilities, and difficulty in walking. Review of the Medicare Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #45 requested extensive assistance from two staff for bed mobility and total dependence from two staff to complete transfers. Resident #45 required extensive assistance to total dependence from one to two staff to complete all other Activities of Daily Living (ADLs). Resident #45 had functional limitations with impairments on one side of both the upper extremity and lower extremity. Resident #45 had two unstageable pressure ulcer areas present upon admission and had surgical wounds present. Review of physician orders dated October 2023 revealed Resident #45 had the following orders: right heel: cleanse with normal saline (NS), pat dry. Apply betadine to the wound, cover with mepilex, wrap with kerlix; change daily and as needed (PRN) with a start date 08/31/23; right buttocks: cleanse with NS, pat dry. Apply calcium alginate to wound base, cover with foam dressing. Change daily and PRN every night shift with a start date 08/24/23; Cleanse left heel with NS, pat dry and apply mepilex every Tuesday with a start date 08/15/23; Cleanse left shoulder incision with NS, pat dry, and apply clean dry dressing every night shift with start date 08/14/23; and cleanse right hip incision with NS, pat dry, and apply clean dry dressing every night shift with start date 08/14/23. Review of progress note dated 08/14/23 revealed Licensed Practical Nurse (LPN) #288 noted Resident #45 to have a left shoulder surgical incision, right hip surgical incision, left heel unstageable pressure ulcer, right heel unstageable pressure ulcer, right buttock open area, and left buttock open area present at the time of admission. On 08/14/23 at 5:29 P.M., Licensed Practical Nurse (LPN) #610 noted Resident #45 was admitted to the facility with bilateral heel wounds and bilateral buttocks wounds. Interview via telephone on 10/05/23 at 9:24 A.M. with Wound Certified Nurse Practitioner (WCNP) #607 revealed an initial evaluation visit was completed on 08/24/23 with Resident #45 to evaluate his wounds. WCNP #607 revealed at the time of his visit, Resident #45 had two areas, on his right heel and right buttocks. WCNP #607 stated Resident #45 did not have wounds on his left heel or left buttocks. Review of the care plan dated 08/14/23 revealed Resident #45 had alteration in skin integrity to bilateral heels related to pressure and alteration in skin integrity to bilateral buttocks related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 14 of 47 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 10/10/2023 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 0657 pressure. The care plan had not been revised to show the current status of Resident #45's wounds. Level of Harm - Minimal harm or potential for actual harm Interview on 10/05/23 at 11:00 A.M. with the Director of Nursing (DON) confirmed Resident #45's care plan had not been revised to show the current status of Resident #45's skin. Residents Affected - Few 2. Review of the medical record for Resident #83 revealed an admission date on 08/29/23. Medical diagnoses included hypertensive heart disease with heart failure, dehydration, urinary tract infection, major depressive disorder recurrent, generalized anxiety disorder, history of falling, muscle weakness, and unsteadiness on feet. Review of the Medicare Five Day MDS 3.0 assessment dated [DATE] revealed Resident #83 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #83 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #83 had a fall two to six months prior to admission, had a fracture related to a fall prior to admission, and had one fall with injury since admission to the facility. Review of the admission Assessment & Baseline Care Plans dated 08/30/23 revealed Resident #83 was at risk for falls with the following interventions implemented: keep wheelchair, walker, belongings, and clothing within reach, low bed, bed alarm, and keep call light in reach. Review of the progress notes revealed Resident #83 had falls on 09/05/23 and 09/07/23 in the facility. Review of the fall investigation dated 09/05/23 revealed a new order for Hydroxyzine 25 milligrams (mg) for anxiety was obtained and neurological checks were initiated for Resident #83. The resident was also noted to have a bed in low position and call light within reach. Review of the fall investigation dated 09/07/23 revealed a new order for Tylenol 325 mg for pain was obtained and neurological checks were initiated for Resident #83. Review of the care plan for Resident #83 revealed the resident was at risk for falls characterized by a history of falls and impaired mobility. Interventions included assist with all transfers, locomotion, mobility, fall risk assessment quarterly and as needed (PRN), and therapy to screen and treat as necessary per physician order. The care plan did not include: keep call light within reach, keep personal items within reach, keep bed in low position, administer medications as ordered, or complete neurological checks for any unwitnessed falls as indicated in the fall investigations and baseline care plan to address Resident #83's falls. Interview on 10/05/23 at 11:00 A.M. with the DON confirmed Resident #83's comprehensive care plan did not include all interventions to address the resident's falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 15 of 47 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 10/10/2023 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** 2. Review of the medial record for Resident #1 revealed an initial admission date of 04/27/23 with diagnoses including pneumonia, metabolic encephalopathy, dysarthria, dementia, depression, cerebral infarction, osteoarthritis, dysphagia, generalized muscle weakness and repeated falls. Residents Affected - Few Review of the plan of care dated 07/13/23 revealed the resident had a self-care performance deficit related to CVA and dementia. Interventions included staff to assist with activities of daily living (ADL) as needed, monitor for fatigue and provide rest periods as needed and reassess quarterly and as needed. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident has a moderate cognitive deficit. The resident required limited assistance of one staff with transfers, ambulation, and was dependent on one staff for bathing. Review of the facility shower schedule revealed the resident was scheduled for showers every Monday and Thursday on the evening shift. Review of the recreation admission assessment dated [DATE] revealed it was very important to the resident to choose what type of bathing she received. Further review revealed the resident preferred showers. Review of the resident's shower documentation for July 2023 revealed the resident had nine opportunities for scheduled showers on Mondays and Thursdays. Resident #1 had not received a scheduled shower or bedbath on 07/03/23, 07/10/23, 07/17/23, 07/24/23 and 07/27/23. Further review of the resident's shower documentation revealed the resident received three showers on non-shower days (07/09/23, 07/13/23, and 07/23/23) and bedbaths on scheduled shower days on 07/07/23. Review of the resident's shower documentation for August 2023 revealed the resident had nine opportunities for scheduled showers on Mondays and Thursdays. Resident #1 had not received a scheduled shower or bedbath on 08/07/23, 08/10/23, and 08/28/23. Further review of the resident's shower documentation revealed the resident received bedbaths on scheduled shower days on 08/03/23, 08/14/23, 08/24/23, and 08/31/23. Review of the resident's shower documentation for September 2023 revealed the resident had eight opportunities for scheduled showers. Further review revealed Resident #1 had not received a scheduled shower on 09/11/23, 09/14/23, 09/18/23, 09/21/23 and 09/25/23. On 10/03/23 at 10:00 A.M., interview with Resident #1 revealed she was not receiving her scheduled showers. Observation during the time of the interview revealed the resident's hair was greasy. On 10/04/23 at 4:02 P.M., interview with the Director of Nursing (DON) #225 verified Resident #1 had not received her scheduled showers. 3. Review of the medical record for Resident #5 revealed an initial admission date of 11/16/22 with the admitting diagnoses including acute and chronic respiratory failure with hypoxia, dementia, dysphagia, severe morbid obesity, sarcopenia, hypertension, gastro-esophageal reflux disease, vitamin D deficiency, atrial fibrillation, bipolar disorder, osteoporosis, polyneuropathy, insomnia and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 16 of 47 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 10/10/2023 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 chronic pain syndrome. Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had no behaviors. The resident required extensive assistance of two for bed mobility, transfers, toilet use, dressing, personal hygiene and bathing. Residents Affected - Few Review of the plan of care dated 11/17/22 revealed the resident has a self-care deficit with potential for fluctuations and/or decline related to recent hospitalization, multiple health conditions, dementia, obesity, chronic pain, bipolar disorder and atrial fibrillation. Interventions included assist to bathe/shower as needed, assist with daily hygiene, grooming, dressing, oral care and eating as needed and therapy evaluation and treatment per physician orders. Review of the recreation progress note and assessment dated [DATE] revealed it was very important to the resident to choose the type of bathing she received. The assessment indicated the resident preferred showers in the morning twice weekly. Review of the facility shower schedule revealed the resident's showers were scheduled every Sunday and Thursdays on night shift. Review of the resident's shower documentation for July 2023 revealed the resident had nine opportunities to receive a scheduled shower on Sunday and Thursday. Resident #5 had not received a shower or bedbath on 07/02/23, 07/06/23, 07/09/23, 07/13/23 and 07/16/23. Further review of the resident's shower documentation revealed the resident received two showers in the month of July on non-shower days (07/04/23 and 07/18/23) and bedbaths on scheduled shower days of 07/20/23, 07/23/23, 07/27/23 and 07/30/23. Review of the resident's shower documentation for August 2023 revealed the resident had nine opportunities to receive a scheduled shower on Sunday and Thursday. Resident #5 had not received a shower or bedbath on 08/10/23, 08/13/23 and 08/24/23. Further review of the resident's shower documentation revealed the resident received three showers on non-shower days (08/02/23, 08/18/23 and 08/25/23) and bedbaths on scheduled shower days on 08/06/23, 08/17/23, 08/20/23, 08/27/23 and 08/31/23. Review of the resident's shower documentation for September 2023 revealed the resident had eight opportunities to receive a scheduled shower on Sunday and Thursday. Resident #5 had a not received a shower on 09/07/23, 09/17/23 and 09/21/23. Further review of the resident's shower documentation revealed the resident received two showers on non-shower days (09/08/23 and 09/29/23) and bedbaths on scheduled shower days on 09/03/23, 09/10/23, 09/14/23, 09/25/23 and 09/28/23. Review of the resident's shower documentation for October 2023 revealed the resident did not receive her scheduled shower on 10/01/23. On 10/04/23 at 4:02 P.M., interview with the DON #225 verified Resident #1 had not received her scheduled showers. Review of the facility policy titled, Bed Bath/Shower, last revised 06/30/23 revealed residents will be scheduled to accommodate their preferences as facility is able and will be scheduled at least weekly. The staff will complete the bath/shower as scheduled or to accommodate the resident's preference. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 17 of 47 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 10/10/2023 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 This deficiency represents non-compliance investigated under Complaint Number OH00146341. Level of Harm - Minimal harm or potential for actual harm Based on observation, record reviews, interviews, and policy review, the facility failed to ensure three residents (#1, #5 and #61) who were dependent on staff for bathing received scheduled showers and according to preference. This affected three (Resident #1,#5, and #61) of three residents reviewed for activities of daily living (ADLs). The facility census was 92. Residents Affected - Few Findings Included: 1. Review of the medical record for Resident #61 revealed an admission date of 06/01/21 with diagnoses including unilateral primary osteoarthritis of the left knee, generalized muscle weakness, reduced mobility, cerebral infarction, and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #61 had intact cognition. Resident #61 required extensive one person assistance for personal hygiene. Review of the recreation progress note and assessment dated [DATE] revealed it is very important for Resident #61 to choose which type of bath he wants to take. When choosing between a bed bath or shower Resident #61 chose a shower. Resident #61 prefers to shower in the morning once a week. Review of the plan of care dated 09/07/23 revealed Resident #61 had a preference to bathe in the morning and take one shower a week. Review of the facility shower schedule revealed Resident #61 was scheduled for showers every Tuesday and Friday on the night shift. Review of Resident #61's shower documentation for July 2023 revealed the resident had eight opportunities for scheduled showers. The resident received only one shower for the month of July 2023 on 07/20/23. Review of Resident #61's shower documentation for August 2023 revealed the resident had nine opportunities for scheduled showers. The resident did not receive a shower for the month of August 2023. Review of Resident #61's shower documentation for September 2023 revealed the resident had nine opportunities for scheduled showers. The resident received only one shower for the month of September 2023 on 09/19/23. Interview on 10/05/23 09:55 A.M. with Resident #61 revealed he does not get a shower when he wants one. Interview on 10/05/23 at 10:38 A.M. with Clinical Service Manager #602 verified shower sheet documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 18 of 47 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 10/10/2023 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 observations, resident and staff interviews and record review, facility failed to ensure meaningful activities were offered and provided. This affected one Resident (#146) of three reviewed for activities. Facility census was 92. Residents Affected - Few Findings include Review of the medical record for the Resident #146 revealed an admission date of 09/22/23. Diagnoses included syncope and collapse, diabetes type two, kidney failure, hemiplegia, and muscle weakness. Review of the not completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Review of the plan of care dated 09/25/23 revealed Resident #146 had potential for decreased activity participation, involvement and/or social isolation related to immobility with interventions: if resident chooses to not attend organized activities, turn on TV or music or provide sensory stimulation and invite resident to attend scheduled activities. Review of the activity assessment dated [DATE] revealed Resident #146 was interested in the past in card games (poker), and had present interest in sports, R and B music, being outdoors, voting, and religious/Christian activities. Review of the activity tasks dated 09/22/23 to 10/05/23 revealed resident was only documented as participating in independent activity and watching television. Puzzles: none found Outdoors: none found Music: not available 09/24/23 and 10/01/23 Movie: not available 09/28/23 Books: none found (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 19 of 47 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 10/10/2023 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 Election: none found - Residents Affected - Few Discussion: not available 09/25/23, 09/27/23, 10/02/23 Craft: none found Current event: not available 09/25/23, 09/27/23, 10/02/23 Cornhole: none found Coffee Club: not available 09/25/23, 09/26/23, 09/28/23, 09/29/23, 10/02/23, 10/03/23, 10/04/23 One to one visit: none found Audio book: none found Bingo: not available 09/25/23, 09/27/23, 09/28/23 10/02/23 Bowling: not available 10/04/23 Facility failed to provide evidence of Resident #146 attending any activities for the first few days of 10/2023 after requests were made several times on 10/04/23 and 10/05/23. Interview on 10/02/23 at 11:28 A.M. with Resident #146 reported facility did not have activities he was aware of. He revealed he had not been invited to activities and did not know where or how to attend activities listed on the calendar. Observations on 10/02/23 at 9:00 A.M., 10:35 A.M., 11:40 A.M., 1:50 P.M., 3:30 P.M., and 5:10 P. M. revealed Resident #146 was not participating in any activities. No activities staff were observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 20 of 47 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 10/10/2023 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 on the 100 hall inviting residents to activities at these times. Level of Harm - Minimal harm or potential for actual harm Observation on 10/02/23 at 11:40 A.M. revealed facility did not have the activity calendar posted in any common hallways or areas including outside the activity room dining room and any main hallways. A large size calendar was posted in a hall near the activity room but was blank during observation. Residents Affected - Few Observations on 10/03/23 at 8:10 A.M., 10:50 A.M., 11:20 A.M., 12:50 P.M., 2:13 P.M., 3:05 P.M., and 4:50 P. M. revealed Resident #146 was not participating in any activities. No activities staff were observed on the 100 hall inviting residents to activities at these times. Observation on 10/03/23 at 11:20 A.M. revealed facility did not have the activity calendar posted in any common hallways or areas including outside the activity room dining room and any main hallways. A large size calendar was posted in a hall near the activity room but was blank during observation. Interview and observation on 10/04/23 at 8:50 A.M. with LPN #606 revealed she had not seen residents on the hall getting up and out of bed for any activities. Interview and observation on 10/04/23 at 8:56 A.M. with State Tested Nursing Aide (STNA) #263 revealed typically the activities brought a daily paper by the rooms that has information the daily events. STNA went into four separate resident rooms on the hall and confirmed with each resident that they had not received the daily paperwork Continuous observation on 10/04/23 from 8:50 A.M. to 10:55 A.M. revealed Resident #146 had been in his room the entirety of the observation without any staff entering the room and inviting him to activities. Observation and interview on 10/04/23 at 10:55 A.M. with Activity Director #252 revealed no organized activities were going on in the activity room. Two residents were sitting in the activity room talking. Activity Director revealed she took attendance for all activities. Interview on 10/05/23 at 10:52 A.M. with Physical Therapist # 610 confirmed he was brought to the survey team room by Clinical Service Manager #601 to show resident #146 had been out of bed with therapy during surveyor observations. Physical Therapist confirmed Resident #146 had not actually worked with physical therapy since 09/29/23 and was scheduled to work with then again on 10/05/23 afternoon. Physical Therapist denied taking residents to the activity room after therapy services were rendered during the week of observations from 10/02/23 to 10/05/23. Interview on 10/05/23 at 11:25 A.M. with Activity Director (AD) #252 revealed Resident #146 refuses all activities. Resident revealed she should go room to room and invite residents to each activity 30 minutes prior to each activity. AD revealed if a resident refused an activity, she would mark it as refused on the task list. AD revealed resident not available would be marked if resident was working with medical staff, therapy, or sleeping during the invitation visit. AD revealed Resident #146 had not gone to any activity this week. AD did not have a response to the observation 10/04/23 from 8:50 A.M. to 10:55 A.M. of activity staff not inviting residents on the 100-hall to the morning activities. AD also did not have a response when asked about resident preferences and revealed she was not aware of his preference for music, religious and outdoor activities. When asked about the activity sheet mentioned by floor staff, AD revealed it was likely the daily chronicle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 21 of 47 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 10/10/2023 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 activity calendar dated 10/2023 revealed on 10/02/23 facility had activities from 9:15 A.M. to 5:00 P.M. including daily chronicle, brew crew, current events, activity cart, bingo, and arts and crafts. On 10/03/23 facility had activities from 9:15 A.M. to 5:00 P.M. including daily chronicle, catholic visit, brew crew, cooking club, exercise, and pokeno. On 10/04/23 facility had activities from 9:15 A.M. to 4:00 P.M. including daily chronicle, brew crew, current events, menu assist, bowling, and bible study. Residents Affected - Few Review of facility policy titled Recreation Programs, dated 06/08/22, revealed facility recreation program was designed to meet the needs of the residents and shall be available on a daily basis. Scheduled activities were to be posted on the bulletin board. Residents shall be encouraged to attend activities and participate in activities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 22 of 47 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 10/10/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to comprehensively assess one resident's (#78) Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer on admission, readmission and weekly there after. This affected one (Resident #78) of two residents reviewed for pressure ulcers. The facility census was 92. Residents Affected - Few Findings Included: Review of the medical record for Resident #78 revealed an initial admission date of 03/21/23 with the latest readmission of 08/02/23 with diagnoses including disease of digestive system, osteomyelitis, diabetes mellitus, cerebrovascular accident (CVA) with right sided hemiplegia, obstructive and reflux uropathy, moderate protein calorie malnutrition, seizures, stage IV pressure ulcer to sacral region, chronic pancreatitis, anemia and hypertension. Review of the admission/re-admission evaluation dated 03/21/23 revealed the resident was admitted to the facility with a stage IV pressure ulcer to the right buttocks. The assessment was absent of measurements and description of the stage IV pressure ulcer. Review of the plan of care dated 03/22/23 revealed the resident had a stage IV pressure ulcer to the sacral region. Interventions included administer treatment per physician orders, elevate heels as able, encourage and assist as needed to turn and reposition, use assistive devices as needed, follow up care with physician as ordered, obtain labs as ordered and report results to physician, pressure reducing surface in bed, report evidence of infection, use pillows and/or positioning devices as needed and wound vac per physician orders. Review of the medical practitioner wound progress note dated 03/23/23, two days following the resident's admission to the facility revealed the resident was admitted to the facility with a Stage IV pressure ulcer to the sacrum measuring 9.0 centimeters (cm) by 8.5 cm by 1.0 cm with undermining around the clock. The wound base was made up of granulation tissue and slough. The assessment failed to document the percentage of slough and granulation tissue present on wound. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed verbal and physical behaviors towards others and rejected care. The resident required extensive assistance of one staff for bed mobility, toilet use and dependent on one for transfers. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. The assessment indicated the resident was at risk for skin breakdown and had one stage IV pressure ulcer present on admission. The facility implemented a pressure reducing device to bed/chair, nutrition or hydration intervention to manage skin problems and pressure ulcer/injury care. Review of the medical record revealed the resident had no weekly wound assessment of the stage IV pressure ulcer to the resident's sacrum for the weeks of 05/04/23, 06/15/23, 07/13/23, 08/10/23 and 08/17/23. 09/07/23, 09/14/23 and 09/21/23. Review of the medical record revealed the resident had two acute care hospital stays. Further review revealed no readmission assessment of the Stage IV pressure ulcer to the sacrum on 06/30/23 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 23 of 47 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 10/10/2023 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 0686 08/02/23. Level of Harm - Minimal harm or potential for actual harm Review of the most recent wound assessment dated [DATE] revealed the stage IV pressure ulcer measured 4.0 cm by 2.5 cm by 1.0 cm with undermining (The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface.) from 9 o'clock to 12 o'clock with the 3.0 cm depth at 9 o'clock. The wound was 90% hypergranulation and 10% yellow necrosis. Residents Affected - Few Review of the monthly physician orders for October 2023 identified orders dated 08/03/23 cleanse stage IV pressure ulcer with normal saline, pat dry, gently pack wound with sliver alginate and cover with ABD pad every shift. On 10/04/23 at 4:05 P.M., interview with the Director of Nursing (DON) #225 was notified of the absence of the readmission and weekly assessments. The facility provided no documented evidence the assessments to the stage IV pressure ulcer to the resident's sacrum. Review of the facility policy titled, Skin Care Management, last revised 06/08/23 revealed residents with identified skin breakdown will have a documented skin assessment weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 24 of 47 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 10/10/2023 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 12. Review of the medical record for the Resident #79 revealed an initial admission date of 01/24/23 with several trips out to the hospital. Diagnoses included encephalopathy, fracture of the upper end right humerus, fracture of the third metacarpal left hand, fracture of the fifth metacarpal left hand, muscle weakness, liver cirrhosis and seizures. Review of fall admission assessment dated [DATE] revealed residents cognitive status had changed in the previous seven days and also revealed resident was confined to a chair with no previous falls. Review of the MDS assessment dated [DATE] revealed Resident #79 was cognitively intact and required assistance from staff for mobility. Review of Occupational Therapy (OT) notes dated 07/25/23 to 08/02/23 revealed resident used the wheeled walker and wheelchair for support when ambulating. OT notes revealed resident had poor attention, short term memory, concentration and safety awareness requiring verbal cues. Review of Physical Therapy (PT) notes dated 07/25/23 to 08/03/23 revealed resident had a high fear of falls scoring 5/6 in falls assessment. Resident had reported falls in the previous six months, medium probability of a fall in the next few months and findings of resident having a high risk of falling. Review of the progress notes dated 08/01/23 revealed resident returned from the hospital. Progress note dated 08/04/23 revealed Resident had left that morning (08/03/23) and family called (morning of 08/04/23) reporting resident was in the hospital after a fall. Progress note dated 08/10/23 revealed resident was readmitted to the facility with fractures of her right arm and left hand. Review of Speech Therapy (ST) Discharge summary dated [DATE] revealed resident had min to moderate cognitive - communication skills with impairment in strategies in returning home. Review of the sign out log revealed resident signed out on 08/03/23 at 10:15 A.M. and never signed back in. Review of the fall investigation report undated revealed Resident #79 had a fall on 08/03/23 and revealed she was out on LOA when the fall occurred. The investigation revealed majority of the sections were left blank or written in as unknown or not applicable due to resident on LOA. The investigation did not include what interventions were in place and what factors may have led to the fall. Review of Physician note dated 08/03/23 revealed resident had reported to medical staff she had lived at facility for past nine months and went to the grocery store. She tripped on a curb and fell forward with head injury, shoulder and wrist pain with episode of dizziness. Resident had a history of previous injury of distal radial fracture on 05/08/23. Review of the hospital Discharge summary dated [DATE] revealed resident was admitted [DATE] after sustaining a fall with head injury and right shoulder pain. Resident was diagnosed with acute right proximal humeral fracture and acute fracture of the third through fifth metacarpal bones, right frontal and periorbital scalp swelling and hematoma due to traumatic fall, and recurrent falls with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 25 of 47 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 10/10/2023 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 bilateral lower extremity edema, vertigo, acute hepatic encephalopathy, decompensated liver cirrhosis. Level of Harm - Minimal harm or potential for actual harm Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact with a BIMS of 13 and required extensive assistance of one staff members for bed mobility, transfers, and limited to extensive assist of one person (physical assist) for ambulation and locomotion. The MDS revealed Resident #79 had a fall with major injury recently. Residents Affected - Some Review of the plan of care dated 08/28/23 revealed Resident #79 had alteration in neurological status related to encephalopathy with interventions for cueing reorientation as needed and obtain lab work as ordered. Resident had alteration in musculoskeletal status with fracture of the left hand and right humerous with interventions to anticipate needs, keep call light in reach and follow orders for weight bearing status. Resident was at risk for falls related to weakness, impaired mobility with a history of falls and a fall while on leave of absence with interventions to assist with transfers locomotion and mobility, fall risk assessment and non-slip footwear. Review of physician orders revealed no current or past physician orders were placed for Leave of Absence (LOA). Resident had several therapy orders ranging from 01/2023 to 08/2023. Review of the medical record found no evidence of previous falls being taken into account for falls risk assessment prior to the fall on 08/03/23. Facility also did not have any evidence of a leave of absence assessment or safety assessment to determine appropriateness of resident going on leave of absence. Facility did not have any fall interventions in place related to mobility and precautions for resident to take when out on leave of absence. Interview and observation on 10/02/23 at 2:33 P.M. with Resident #79 revealed she broke her arm and hand in a fall. Resident had a cast on her right arm. Resident revealed she falls frequently but was unable to remember any details of the fall and appeared to have altered mental status. Interview on 10/03/23 at 5:55 P.M. with DON revealed Resident had a BIMS of 13 and was able to sign herself out on leave of absence (LOA). DON revealed Resident #79 had a long history of falls out in the community and was unable to provide evidence facility had assessed for safety while on LOA and was unable to provide evidence resident had any fall interventions in place while on leave of absence. DON revealed residents should have LOA order from the physician if able to go on LOA and provided no evidence of an LOA order being in place at the time of the fall with major injury. DON confirmed facility completed the fall investigation due to resident being admitted and being our responsibility. DON confirmed she was not aware if staff spoke with resident and/or family in relation to details of the fall and confirmed almost all sections were marked as unknown and not applicable resident on LOA. DON confirmed the investigation did not include what interventions were in place and what factors may have led to the fall. Review of the facility policy, Falls-Clinical Protocol, reviewed 06/08/22, revealed the policy stated, for an individual who has fallen, staff will attempt to define possible causes. A fall assessment and pain assessment to be completed. Care plan to be reviewed and revised as appropriate. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Based on medical record review, observations, resident and staff interviews, and facility policy review, the facility failed to implement a safe smoking program, including assessing nine residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 26 of 47 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 10/10/2023 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 identified as smokers (Residents #9, #30, #32, #57, #68, #73, #87, #145, and #148) for safe smoking. The facility also failed to implement fall interventions following resident falls for three residents (Residents #79, #83, and #145). Finally, the facility failed to ensure a resident (Resident #45) was properly secured in the transport van, resulting in the resident sliding out of his wheelchair. This affected 12 residents (Residents #9, 30, 32, 45, 57, 68, 73, 79, 83, 87, 145, and 148). The facility census was 92. Residents Affected - Some Findings Include: 1. Review of the medical record for Resident #9 revealed an admission date on 06/03/20. Medical diagnoses included other seizures, multiple sclerosis, dysphagia, major depressive disorder recurrent, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition and scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #9 required extensive assistance to total dependence on one to two staff to complete Activities of Daily Living (ADLs). Review of the current physician orders dated October 2023 revealed Resident #9 did not have any orders related to safe smoking. Further review of the physician orders revealed an order that Resident #9 may go on Leave of Absence (LOA) was added on 10/03/23 (after surveyor intervention). Review of resident assessments for Resident #9 revealed there were no completed smoking evaluations. Further review of resident assessments, revealed a Smoking Evaluation was completed on 10/03/23 (after surveyor intervention). The evaluation revealed Resident #9 did not smoke in designated smoking areas and did not demonstrate compliance with the facility smoking rules. Resident #9 was able to smoke independently and unsupervised. Review of the care plan for Resident #9 revealed on 10/03/23 (after surveyor intervention), Resident #9 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). 2. Review of the medical record for Resident #30 revealed an admission date on 08/25/23 and a discharge date on 10/03/23. Medical diagnoses included alcohol dependence with withdrawal, history of nicotine dependence, and Chronic Obstructive Pulmonary Disorder (COPD). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #30 was independent with set up help only to requiring supervision from one staff to complete ADLs. Review of the physician orders dated October 2023 revealed Resident #30 did not have any orders related to safe smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 27 of 47 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 10/10/2023 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 Further review, revealed an order dated 10/03/23 (after surveyor intervention) that indicated Resident #30 may go on LOA was entered. Review of resident assessments for Resident #30 revealed there were not any smoking evaluations completed. Residents Affected - Some Further review, revealed a Smoking Evaluation was completed on 10/03/23 (after surveyor intervention). The evaluation indicated Resident #30 was able to smoke independently and unsupervised. Review of a progress note dated 09/29/23 at 9:45 A.M. revealed Resident #30 was visited by the Certified Nurse Practitioner (CNP) at bedside. Resident #30 stated he was ready to go outside to smoke. Resident #30 stated he was going to smoke until the end and no one could make him stop. Resident #30 was an active smoker on a daily basis and unmotivated to quit. Review of the care plan for Resident #30 revealed on 10/03/23 (after surveyor intervention), Resident #30 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). 3. Review of the medical record for Resident #32 revealed an original admission date on 08/12/22 and a re-admission date on 09/27/22. Medical diagnoses included type II diabetes mellitus with proliferative diabetic retinopathy with macular edema right eye, end stage renal disease, dependence on renal dialysis, and muscle weakness. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #32 had intact cognition and scored 14 out of 15 on the BIMS assessment. Resident #32 required supervision from one staff to complete ADLs. Review of the physician orders dated October 2023 revealed Resident #32 had an order that indicated may go LOA with medications overnight dated 06/15/23. Review of resident assessments for Resident #32 revealed no smoking evaluations had been completed. Further review, revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention). The evaluation indicated Resident #32 did not smoke in designated smoking areas and did not demonstrate compliance with facility smoking rules. Resident #32 was not safe to smoke independently or unsupervised. Resident #32 was non-compliant with smoking policy and would choose to not smoke in the designated area. Resident #32 would become verbally aggressive when reeducated on the policy and where smoking could take place. Review of the care plan for Resident #32 revealed on 10/03/23 (after surveyor intervention), Resident #30 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 28 of 47 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 10/10/2023 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 - Some 4. Review of the medical record for Resident #57 revealed an original admission date on 07/28/23, a readmission date on 08/18/23, and a discharge date on 10/03/23. Medical diagnoses included end stage renal disease, dependence on renal dialysis, unqualified visual loss both eyes, encephalopathy, cognitive communication deficit, and muscle weakness. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #57 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #57 required a varied amount of assistance to complete ADL's ranging from independent with set up help only to supervision with one person assistance to extensive assistance from one staff for toileting. Review of the physician orders dated October 2023 revealed Resident #57 did not have any orders related to safe smoking. Further review, revealed an order was added on 10/03/23 (after surveyor intervention) that indicated Resident #57 may go on LOA. Review of resident assessments revealed Resident #57 did not have any smoking evaluations completed. Further review, revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #57. The evaluation indicated Resident #57 was able to smoke independently and unsupervised. Review of the care plan for Resident #57 revealed on 10/03/23 (after surveyor intervention), Resident #57 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). 5. Review of the medical record for Resident #68 revealed an admission date on 08/03/23. Medical diagnoses included nondisplaced fracture of lateral malleolus of right fibula (lower leg), pressure ulcer of right heel-unstageable, peripheral vascular disease (PVD), muscle weakness, absence of left foot, and personal history of sudden cardiac arrest. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition and scored 14 out of 15 on the BIMS assessment. Resident #68 required extensive assistance from one to two staff to complete ADLs. Review of the physician orders dated October 2023 revealed Resident #68 did not have any orders in place for safe smoking. Further review revealed an order was added on 10/03/23 (after surveyor intervention) that indicated Resident #68 may go on LOA. Review of resident assessments for Resident #68 revealed no smoking evaluations had been completed. Further review revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #68. The evaluation indicated Resident #68 did not smoke in designated smoking areas (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 29 of 47 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 10/10/2023 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 - Some and did not demonstrate compliance with facility smoking rules. Resident #68 was safe to smoke independently and unsupervised. Review of the care plan for Resident #68 revealed on 10/03/23 (after surveyor intervention), Resident #68 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). Interview on 10/02/23 at 5:09 P.M. with Resident #68 revealed she was aware she was not following the smoking policy at the facility. Resident #68 stated the administration wanted the residents to leave the facility's property in order to smoke. Resident #68 stated she attempted to go down the driveway once in her wheelchair and was not able to stop and ended up out in the street in her wheelchair. Resident #68 stated facility staff never assisted the residents outside. Resident #68 stated she signed out at the front desk each time she went out to smoke and signed back in when she re-entered the facility. Resident #68 stated she kept her lighter and cigarettes on her person at all times. Resident #68 showed this surveyor an opened pack of cigarettes and lighter that were tucked beside her in her wheelchair. 6. Review of the medical record for Resident #73 revealed an admission date on 02/28/23. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disorder (COPD), muscle weakness, and thoracic aortic aneurysm without rupture. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #73 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #73 required a varied amount of assistance ranging from independent with set up help only to supervision with one staff to extensive assistance from one staff for eating to complete ADLs. Review of the physician orders dated October 2023 revealed Resident #73 did not have any orders in place for safe smoking. Further review revealed an order dated 10/03/23 (after surveyor intervention) was entered that indicated Resident #73 may go on LOA. Review of resident assessments revealed there were not any smoking evaluations completed for Resident #73. Further review revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #73. The evaluation indicated Resident #73 did not smoke in designated smoking areas and did not demonstrate compliance with facility smoking rules. Resident #73 was safe to smoke independently and unsupervised. Review of the care plan for Resident #73 revealed on 10/03/23 (after surveyor intervention), Resident #73 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 30 of 47 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 10/10/2023 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 - Some 7. Review of the medical record for Resident #87 revealed an admission date on 09/11/23. Medical diagnoses included Huntington's Disease, acute respiratory failure with hypoxia, other seizures, dysphagia, muscle weakness, and nicotine dependence. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #87 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #87 required extensive assistance to total dependence from one to two staff to complete ADL's. Review of the physician orders dated October 2023 revealed Resident #87 did not have any orders related to safe smoking. Further review revealed an order dated 10/03/23 (after surveyor intervention) was entered that indicated Resident #87 may go on LOA. Review of resident assessments revealed there were not any smoking evaluations completed for Resident #87. Further review revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #87. The evaluation indicated Resident #87 did not smoke in designated smoking areas and did not demonstrate compliance with facility smoking rules. Resident #87 was not able to safely use a lighter and was not able to safely extinguish smoking materials. Resident #87 was not safe to smoke unsupervised. Resident #87 was dependent on her spouse to assist her to the designated area and lighting her cigarettes. The resident's spouse also extinguished her material for her. Resident #87's spouse was educated on the policy and the designated smoking area. Review of the care plan for Resident #87 revealed on 10/03/23 (after surveyor intervention), Resident #87 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). Observations on 10/02/23 at 11:33 A.M., 10/02/23 at 12:11 P.M., and 10/02/23 at 1:20 P.M. revealed Resident #87 was outside with her spouse and other residents smoking cigarettes. Resident #87 was observed smoking on the sidewalk to the right of the entrance door on the facility's property and on the sidewalk to the left of the first driveway leading to the parking lot of the facility. There were not any ashtrays visible in either area where residents were observed to be smoking. 8. Review of the medical record for Resident #145 revealed an admission date on 09/21/23 and a discharge date on 10/06/23. Medical diagnoses included chronic obstructive pulmonary disease (COPD), nicotine dependence-cigarettes, and muscle weakness. Review of Resident #145's admission fall assessment dated [DATE] revealed resident had one to two falls in the last 90 days, resident required assistance with toileting with interventions for low bed, bed alarm and to keep call light in reach. Review of Resident #145's baseline care plan dated 09/22/23 for falls revealed interventions included call light in reach, verbal cues for safety awareness, assistive device (walker), clutter free and non-slip socks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 31 of 47 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 10/10/2023 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 Review of the progress notes dated 09/22/23 revealed Resident was newly admitted and at 9:40 P.M. her husband informed staff that resident had fallen out of bed with head injury. On 09/22/23 Nurse practitioner note revealed resident reported having two falls. Resident recommended to go to the hospital and resident refused. On 09/22/23 progress note stated fall interventions of low bed, common items within reach, and call light within reach. Residents Affected - Some Review of fall investigation dated 09/22/23 revealed residents slipped out of bed when attempting to self-transfer. The investigation included admission vitals and not vitals post fall, details such as footwear during the fall was not included. Time was changed from 8:03 P.M. to 9:40 P.M. on the investigation report. On 09/24/23 revealed Resident aide witnessed resident sliding from wheelchair to floor. When asked about the fall resident informed staff she was going to go outside to smoke. Interventions included night light, keep items within reach, bedside commode, nonskid footwear, low bed and bell on wheelchair. Progress note from physician dated 09/26/23 (service date 09/25/23) revealed resident had three falls and talked with administrator about getting bed rails. Review of fall investigation dated 09/25/23 revealed residents fell at 11:57 P.M. when she slid out of her wheelchair onto the floor. Resident was alone and unattended and Resident reported she was trying to go outside to smoke. The investigation did not include footwear at the time of the falls. The last reported toileting check was at 3:00 P.M. Review of the Medicare Five Day MDS 3.0 assessment dated [DATE] revealed Resident #145 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #145 required a varied amount of assistance from supervision to limited assistance to extensive assistance from one to two staff to complete ADLs. Review of the physician orders dated October 2023 revealed Resident #145 did not have any orders related to safe smoking. Further review revealed an order dated 10/03/23 (after surveyor intervention) was entered that indicated Resident #145 may go on LOA. Resident #145 also had an order for oxygen at two liters per minute via nasal cannula as needed for shortness of breath dated 10/03/23. Review of resident assessments revealed there were not any smoking evaluations completed for Resident #145. Further review revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #145. The evaluation indicated Resident #145 did not smoke in designated areas and did not demonstrate compliance with smoking rules. Resident #145 was able to smoke independently and unsupervised. Resident #145 was non-compliant with the smoking policy and chose to not smoke in the designated area and was unable to be redirected successfully. Review of the care plan for Resident #145 revealed on 10/03/23 (after surveyor intervention), Resident #145 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 32 of 47 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 10/10/2023 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 - Some Facility was unable to provide evidence of what interventions were determined after each fall to protect resident from future falls and also failed to provide evidence of appropriate interventions being put into place after each fall. This information was requested on 10/03/23, 10/04/23 and 10/05/23. Observations on 10/02/23 at 9:20 A.M., 10:50 A.M., 1:40 P.M., 4:30 P.M. and on 10/03/23 at 8:10 A.M., 9:55 A.M., 11:10 A.M., 2:05 P.M. 5:30 P.M. revealed resident's bed was not in low position and resident did not have bed rails installed on her bed. Interview on 10/03/23 at 5:55 P.M. with DON revealed Resident #145 only had two falls the day she admitted to the facility (09/22/23) and none since. When shown the progress notes related to the fall on 09/24/23, DON revealed she would need to look into it. DON revealed resident could reach the remote and adjust the height of the bed. DON reported the facility had a process to get the bed rails as the previous ownership did not allow bed rails and revealed she would need to look into what the facility had done regarding bed rail request. Facility failed to provide any evident related to bed rails being order as a fall precaution and mobility aide for Resident #145. Interview on 10/04/23 around 11:00 A.M. with DON reported resident only had one fall the day of admission [DATE]) and a second fall a few days later (09/24/23). DON revealed staff documented the first fall twice which led to the confusion of three falls. 9. Review of the medical record for Resident #148 revealed an admission date on 09/21/23. Medical diagnoses included acute respiratory failure with hypoxia, metabolic encephalopathy, acquired absences of right and left legs above the knee, and muscle weakness. Review of the admission MDS 3.0 assessment dated [DATE]. Resident #148 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #148 required extensive assistance from one to two staff to complete ADL's. Review of the physician orders dated October 2023 revealed Resident #148 did not have any orders related to safe smoking. Further review revealed an order dated 10/03/23 (after surveyor intervention) was entered that indicated Resident #148 may go on LOA. Review of resident assessments revealed there were not any smoking evaluations completed for Resident #148. Further review revealed a smoking evaluation was completed on 10/03/23 (after surveyor intervention) for Resident #148. The evaluation indicated Resident #148 did not smoke in designated areas and did not demonstrate compliance with smoking rules. Resident #148 was able to smoke independently and unsupervised. Review of the care plan for Resident #148 revealed on 10/03/23 (after surveyor intervention), Resident #148 chose to smoke was initiated. Interventions included to monitor for cognitive or physical functioning changes that may impede the resident's ability to smoke, resident will observe facility smoking policy and smoke in designated areas and designated smoking times, if the resident was non-compliant with smoking policy review facility smoking policy and document education, and smoking evaluation will be reviewed quarterly and updated as needed (prn). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 33 of 47 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 10/10/2023 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 - Some Review of the Quality Assurance Performance Improvement Sign-In Sheet dated 09/11/23 revealed Residents #9, #30, #32, #57, #68, and #73 attended the smokers meeting to review the policy. Observations made during the survey period from 10/02/23 through 10/05/23 at various times revealed residents were outside in the parking lot and on the sidewalks of the facility's property smoking without any staff supervision. There were not any ashtrays observed in any of the areas the residents were observed to be smoking. Interviews on 10/03/23 at 8:15 A.M., 8:21 A.M., and 8:30 A.M. with Nurse #612, Nurse #614, and Registered Nurse (RN) #209 respectively confirmed the residents did not have to go to the staff and ask for their smoking supplies. The staff stated they had an idea of who smoked in the facility but they did not have an official list of smokers. The residents did not sign out with the nurses but they signed out at the front desk. The residents smoked on the property. The facility did not have a designated smoking area. Interview on 10/03/23 at 8:45 A.M. with the Administrator and Regional Director of Operations (DOO) #603 confirmed the facility was currently a non-smoking facility but was planning to become a smoking facility. The Administrator and DOO #603 confirmed they facility did not have everything set up to be a safe smoking facility right now but was planning to start working on it soon. The Administrator and DOO #603 stated they would need to work on gathering the names of residents who were currently smoking at the facility from other staff. All residents who smoked should have an order in place that allowed them to go on leave of absence (LOA). Interview on 10/03/23 at 5:50 P.M. with the Director of Nursing (DON) confirmed the facility had not been completing smoking evaluations to determine if residents were safe to be smoking unsupervised but allowed residents to keep their smoking materials on their person and in their rooms. The DON confirmed there were residents who needed to use oxygen in the facility. The DON confirmed the facility did not have a smoking policy in place because the facility had maintained that it was a non-smoking facility however, staff were aware that residents were smoking in the parking lot and on the sidewalks of the facility's property. Review of the facility policy, Non-Smoking Policy, reviewed 06/08/22, revealed the policy stated, the facility was non-smoking&[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 34 of 47 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 10/10/2023 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of hospital records, and interview, the facility failed to timely identify and assess symptoms of a urinary tract infection (UTI), accurately collect a sample of urine for testing, and notify the physician of contaminated urine specimens for Resident #24. Additionally, the facility failed to remove Resident #52's indwelling urinary catheter following the collection of a 24-hour urine. Actual harm occurred beginning on 07/04/23 when the facility failed to identify symptoms of UTI, treat the UTI with the appropriate antibiotics, and notify the physician of multiple contaminated urine samples causing Resident #24 to sustain a significant decline in condition. On 08/04/23 the resident was transferred to an acute care hospital for confusion and suicide attempt and was found to have a UTI. The resident was hospitalized for nine days and required intravenous (IV) antibiotics to treat the urinary tract infection. This affected two residents (#24 and #52) of two residents reviewed for UTI and/or indwelling catheter use. The facility census was 92. Findings Include: 1. Review of the medical record for Resident #24 revealed an initial admission date of 11/02/18 with the most recent re-admission of 08/12/23. Resident #24 had diagnoses including chronic obstructive pulmonary disease (COPD), heart disease, Alzheimer's disease, dementia, bipolar disorder, psychosis, osteoarthritis, obstructive sleep apnea, anxiety disorder, gastro-esophageal reflux disease, hyperlipidemia, mood disorder, hypertension, major depressive disorder, benign prostatic hyperplasia, allergic rhinitis, insomnia, retention of urine, and cerebrovascular accident (CVA). Review of the plan of care dated 02/06/19 revealed the resident had a suprapubic urinary catheter due to disease process and obstructive uropathy. Interventions included catheter care, change catheter per physician order, change urinary collection bag as needed, maintain dignity bag to catheter, maintain drainage bag below bladder level, report to physician signs of urinary tract infection (UTI), secure catheter with securement device, wears pads/briefs as needed, report any changes in amount, color or odor to urine and administer medications per physician's orders. Review of the resident's progress note dated 07/04/23 revealed the resident's spouse reported the resident's urine was dark in color. On assessment by the staff nurse the resident's urine was found to be amber in color with a foul odor. A new physician's order was obtained for a urinalysis/culture & sensitivity (UA/C&S). Review of the medical record revealed the resident's urine was collected on 07/05/23 and was sent to the facility's contracted lab on 07/06/23. The results of the UA/C&S returned on 07/09/23 with the bacteria Escherichia coli (E-coli) greater than 100,000, Providencia stuartii greater than 100,000 and Pseudomonas aeruginosa greater than 100,000. The resident was treated with the antibiotic, Augmentin 500 milligrams (mg) by mouth twice daily for five days. Further review of the UA/C&S revealed the antibiotic, Augmentin was only sensitive to the E-coli. Review of the progress note dated 07/18/23 revealed the resident's wife reported the resident had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 35 of 47 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 10/10/2023 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 0690 increased confusion/hallucinations and a new order was obtained for a UA/C&S. Level of Harm - Actual harm Review of the progress note dated 07/24/23 revealed the resident's wife was at the facility and asked Director of Nursing (DON) #225 to review the UA/C&S results with her which showed the urine was contaminated. The Nurse Practitioner (NP) was notified at that time of the contaminated urine and a new order was obtained for another UA/C&S. Residents Affected - Few On 07/31/23 the NP saw the resident and reviewed the resident's UA/C&S results and started the antibiotic Cipro 500 mg by mouth twice daily for seven days; however, the UA/C&S again showed the urine was contaminated. Review of the progress note dated 08/04/23 at 12:40 P.M. revealed the resident's family wanted the resident transferred to a local emergency department (ED) for an evaluation due to an acute change in mental status. Review of the medical record revealed no documented evidence staff had identified the change in the resident's condition until it was brought to their attention by family (on 08/04/23). Further record review revealed a lack of comprehensive monitoring/assessment of the resident's urinary status during the time period between 07/04/23 and 08/04/23. Review of the acute care hospital history and physical dated 08/04/23 revealed the resident was transferred to the acute care hospital for confusion and suicide attempt and was found to have a UTI. The resident was treated in the hospital with intravenous (IV) antibiotics for nine days. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had displayed hallucinations and delusions, however had displayed no behaviors. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, toileting, dressing and bathing. The assessment indicated the resident had an indwelling urinary catheter and was always incontinent of bowel. On 10/02/23 at 3:28 P.M., an interview with the resident's wife revealed the resident was sick the entire month of July 2023 due to a UTI. She revealed he had a temperature, and the physician ordered a UA/C&S. She said he had two urines come back contaminated and the contracted lab failed to pick up his urine over the holiday weekend. She revealed the facility did not repeat the urine testing until she requested. She revealed the resident continued to become more confused and had increased hallucinations to the point he took his scissors and held them to his throat and stated he wanted to kill himself. She revealed the resident spent nine days in the hospital on intravenous (IV) antibiotics to treat the UTI the facility failed to treat properly. On 10/04/23 at 11:09 A.M., an interview with DON #225 verified the lack of care causing the resident's hospitalization related to the UTI. A request was made during the onsite survey to review the facility policy and procedure related to change in condition; however, no policy was provided. 2. Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent re-admission of 07/24/23. Resident #52 had diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 36 of 47 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 10/10/2023 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 0690 disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Level of Harm - Actual harm Residents Affected - Few Review of the admission assessment and baseline care plan dated 07/24/23 revealed the resident was incontinent of urine. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, and toilet use. The assessment indicated the resident was always incontinent of bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the use of the indwelling urinary catheter. Review of the physician's orders revealed no orders for the use of the indwelling urinary catheter. Review of the medical record revealed no evidence the resident had an indwelling urinary catheter or reason for the indwelling urinary catheter. Review of the resident's discontinued physician orders identified an order dated 08/23/23 to place foley catheter to begin 24-hour urine collection (on 08/23/23). On 10/02/23 at 11:12 A.M., observation of Resident #52 revealed the resident had an indwelling urinary catheter. Further observation revealed the resident's indwelling urinary catheter collection bag was purple in color. On 10/03/23 at 3:35 P.M., an interview with DON #225 verified the resident currently had an indwelling urinary catheter. DON #225 revealed the catheter should have been removed following the collection of the 24 hour urine (on 08/24/23). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 37 of 47 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 10/10/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to administer a nutritional supplement to one resident (Resident #83) as ordered. This affected one resident (Resident #83) of six residents reviewed for nutrition. The facility census was 92. Residents Affected - Few Findings Include: Review of the medical record for Resident #83 revealed an admission date on 08/29/23. Medical diagnoses included hypertensive heart disease with heart failure, dehydration, congestive heart failure (CHF), muscle weakness, and history of falling. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #83 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #83 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #83 was noted to have a weight loss of 5% or more in the last month and was on a therapeutic diet. Review of the physician orders dated October 2023 revealed Resident #83 had the following order for Ensure daily at 12:30 P.M. for decreased oral intake dated 09/07/23. Review of weights for Resident #83 revealed the resident lost nine pounds or 5.33% from 08/30/23 to 09/27/23 (less than 30 days). Resident #83 weighed 169 pounds (lbs) on 08/30/23 and 160 lbs on 09/27/23. Review of the Nutrition assessment dated [DATE] revealed Resident #83 weighed 169 lbs at the time of the assessment. The resident was noted to have a weight loss from 202 lbs to 175 lbs over 180 days which indicated a significant weight loss of 10% in the past 180 days. Resident #83 also had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months and was not on a prescribed weight-loss regimen. It was recommended to add ensure or boost daily. Review of the care plan dated 09/05/23 revealed Resident #83 had an altered nutritional status as evidenced by fluctuating food intake with complaints of not liking the food, CHF and diuretic use. Interventions included diet per registered dietitian recommendation and physician order, administer medications as ordered, encourage adequate fluid and food intakes, monitor and evaluate any significant weight loss, and vitamin and mineral supplementation per physician order. Observation and interview on 10/04/23 at 1:06 P.M. with Resident #83 during lunch meal revealed she had ordered a chef salad without ham but requested turkey and cheese instead. Resident #83 did not receive any meat on her chef's salad and did not receive the nutritional supplement on her lunch tray. Resident #83 confirmed she was supposed to receive an Ensure on her lunch tray. Observation and interview on 10/04/23 at 1:15 P.M. with State Tested Nurse Aide (STNA) #272 confirmed Resident #83 did not receive any turkey on the chef's salad as ordered and did not receive a nutritional supplement (Med Pass today) on her lunch tray either. STNA #272 confirmed Resident #83 did usually receive a nutritional supplement at lunch time. STNA #272 agreed to follow up with kitchen and nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 38 of 47 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 10/10/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview again on 10/04/23 at 2:11 P.M. with Resident #83 and STNA #272 revealed Resident #83 still had not received her nutritional supplement. STNA #272 agreed to follow up with the kitchen again. Observation and interview again on 10/04/23 at 2:15 P.M. with Resident #83 and STNA #272 confirmed Resident #83 did receive nutritional supplement at this time with surveyor intervention. Review of the facility policy, Nutrition Interventions for Significant Weight Loss, undated, revealed the policy stated, registered dietitian will assess monthly or weekly weight changes and will recommend interventions intended to reverse weight loss. Based on resident preferences and/or discussion with the resident and/or responsible party, the dietitian may recommend nutritional interventions to attempt to stabilize or reverse weight loss if clinically warranted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 39 of 47 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 10/10/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure residents had physician's orders in place for dialysis and monitoring of dialysis sites. This affected two ( Resident #28 and #52) of two residents reviewed for dialysis. The census was 92. Residents Affected - Few Findings Included: 1. Review of the medical record for Resident #52 revealed an initial admission date of 07/08/23 with the most recent readmission of 07/24/23 with diagnoses including encephalopathy, diabetes mellitus, chronic kidney disease, severe morbid obesity, atrial fibrillation, bipolar disorder, hypertension, dependence on renal dialysis, end stage renal disease, ischemic cardiomyopathy, anemia, gout and lymphedema. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The assessment indicated the resident received dialysis. Review of the monthly physician's orders for October 2023 failed to identify physician's orders for dialysis, monitoring of the central port used for dialysis and emergency instructions for bleeding at the central port. On 10/02/23 at 3:35 P.M., observation of Resident #52 revealed the resident had a central port to the right clavicle area used for dialysis. The central port was covered with a white island dressing with dried orange substance on the dressing. On 10/03/23 at 3:35 P.M., interview with Director of Nursing (DON) #225 verified Resident #52 had no orders for dialysis, monitoring of the central port used for dialysis and emergency instructions for bleeding at the central port. 2. Review of the medical record for Resident #28 revealed an original admission on [DATE] and a readmission on [DATE]. Medical diagnoses included acute kidney failure, type II diabetes mellitus with chronic kidney disease, chronic kidney disease stage 3b, and dependence on renal dialysis. Review of the care plan dated 03/06/23 revealed Resident #28 had renal insufficiencies and required dialysis. Interventions included check access site for evidence of infection, swelling, or excessive bleeding per facility guidelines and report any abnormalities to physician and dialysis Monday, Wednesday, and Friday at 7:15 A.M. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #28 was independent or required supervision with set up help only to assistance from one staff to complete Activities of Daily Living (ADLs). Resident #28 received dialysis. Review of the current physician orders dated October 2023 revealed there were not any orders in place for dialysis or any orders for monitoring the access site for signs or symptoms of bleeding or infection. A physician's order was added on 10/03/23 (after surveyor intervention) for dialysis but no orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 40 of 47 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 10/10/2023 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 related to monitoring the access site were added. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 10/02/23 at 5:51 P.M. with Resident #28 revealed he attended dialysis treatments three days a week. Resident #28 stated the facility staff do not monitor his access site or check his dressing regularly for any bleeding or signs of infection. Residents Affected - Few Interview on 10/03/23 at 2:50 P.M. with the DON confirmed there were not any orders for Resident #28's dialysis treatments in place. The DON stated the resident's dressing was changed at the dialysis center. The DON confirmed there were no orders in place for monitoring Resident #28's access site for any bleeding or signs of infection. Review of the policy, Hemodialysis/Dialysis Access Care, undated, revealed the policy stated, check for signs of infection at the access site when performing routine care and at regular intervals, the dressing change is done in the dialysis center post-treatment, if dressing becomes wet, dirty, or not intact, the dressing can be changed or padded per physician order, mild bleeding from site (post dialysis), apply pressure to insertion site and contact emergency services and dialysis center. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 41 of 47 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 10/10/2023 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to administer as needed pain medication within parameters as ordered by the physician and failed to attempt non-pharmacological interventions prior to administering as needed pain medication for one resident (Resident #4). This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 92. Residents Affected - Few Findings Include: Review of the medical record for Resident #4 revealed an admission date on 08/31/23. Medical diagnoses included hemiplegia and hemiparesis following stroke affecting right dominant side, dementia without behavioral disturbance, and chronic pain. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #4 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #4 received scheduled pain medication and either received as needed (PRN) pain medications or the pain medication was offered and declined. Resident #4 reported a pain level of three out of ten at the time of the assessment. Review of the current physician orders dated October 2023 revealed Resident #4 had the following orders: Tylenol 325 milligrams (mg) with instructions to give 650 mg (two tablets) by mouth three times a day for pain. The order was dated 09/06/23. Tramadol 50 mg with instructions to give one tablet by mouth every eight hours as needed (PRN) for severe pain. The order was dated 08/31/23. There were not any orders related to non-pharmacological interventions. Review of the Medication Administration Record (MAR) dated September 2023 revealed Tylenol was administered three times daily as ordered. Resident #4 received Tramadol on 09/01/23 for a pain level of five out of ten with ten being the worst pain possible, 09/02/23 for a pain level of five out of ten, 09/03/23 for a pain level of five out of ten, 09/04/23 for a pain level of six out of ten, 09/05/23 for a pain level of five out of ten, and 09/07/23 for a pain level of six out of ten. There were not any non-pharmacological interventions indicated on the MAR. Review of the care plan dated 09/08/23 revealed Resident #4 was at risk for pain and discomfort related to chronic pain. Interventions included encourage non-medicinal interventions to control pain and decrease use of analgesic therapy: repositioning, stretching, exercise, relaxation techniques to assist with pain control and administer pain medication per physician order. Interview on 10/04/23 at 3:40 P.M. with Registered Nurse (RN) #209 revealed for PRN pain medication that was ordered for severe pain, an appropriate pain level would be from seven to ten out of ten with ten being the worst pain. Interview via email on 10/05/23 at 3:36 P.M. with the Administrator and the Director of Nursing (DON) informed of surveyor findings related to PRN pain medications for Resident #4 being administered outside of the parameters on the physician order and requested additional information be submitted if there was any further information to provide. No further information was provided by the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 42 of 47 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 10/10/2023 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview via email on 10/05/23 at 4:33 P.M. with the Administrator confirmed Resident #4's care plan indicated to attempt non-pharmacological interventions prior to administering PRN pain medications. There was no further documentation provided that indicated any non-pharmacological interventions had been attempted with Resident #4. Review of the facility policy, Pain Assessment and Management, reviewed 06/08/22, revealed the policy stated, the purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Furthermore, attempt non-pharmacological interventions prior to administering medication. Review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medications relieve the resident's pain. Event ID: Facility ID: 365611 If continuation sheet Page 43 of 47 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 10/10/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #28 revealed an initial admission date of 03/04/23 with the latest readmission of 07/14/23 with diagnoses including diabetes mellitus, cardiomyopathy, congestive heart failure, hyperlipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, hypertension, end stage renal disease, dependence on hemodialysis and gout. Review of the resident's quarterly MDS dated [DATE] revealed the resident had no cognitive impairment. Review of the monthly physician orders for October 2023 identified orders dated 07/18/23 Fluticasone Propionate nasal suspension 50 micrograms (mcg) with the special instructions to spray two sprays in each nostril daily for allergies. Review of the medical record revealed no self-administration medication assessment to self- administer the Fluticasone Propionate. Review of the resident's plan of care revealed no care plan addressing the resident self-administration of the medications Fluticasone Propionate. On 10/03/23 at 8:54 A.M., observation of Registered Nurse (RN) #209 revealed the RN prepared Resident #28's morning medication. The RN revealed the resident kept the medication Fluticasone Propionate at bedside and she would ask if he took the medication for the morning. The RN delivered the medication to Resident #28 and asked the resident if he took the medication Fluticasone Propionate. The resident stated, I already used the spray. On 10/03/23 at 1:43 P.M., interview with Director of Nursing (DON) #225 verified the resident had no self administration assessment, physician order or care plan to self-administer the medication Fluticasone Propionate. Review of facility policy titled Medication Storage in the Facility, dated 01/2018, revealed medications are to be stored safely and securely. Only licensed nurses, or those authorized to administer medications and medication supplies shall be locked when not attended by persons with authorized access. Based on observation, staff and resident interviews, and record review, the facility failed to ensure medications were not left out at bedside without secure storage and supervision from the nurse. This affected two residents (#28 and #146) of two reviewed for medication storage. Facility census was 92. Findings include 1. Review of the medical record for the Resident #146 revealed an admission date of 09/22/23. Diagnoses included syncope and collapse, diabetes type two, kidney failure, hemiplegia, and muscle weakness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 44 of 47 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 10/10/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the not yet fully completed Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #146 was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. Review of the medical record revealed no evidence of resident having been assessed to self-administer medications. Observation and interview on 10/04/23 at 1:30 P.M. with State Tested Nursing Aide (STNA) #263 and Resident #146 revealed STNA was overheard informing resident your meds are still here when resident's lunch tray was delivered. STNA #263 and Resident #146 both confirmed resident had a cup of pills at bedside and appeared to have an estimate of eight pills before resident took his medications. Interview on 10/04/23 at 1:40 P.M. with Licensed Practical Nurse (LPN) #606 confirmed she left a cup of meds at Resident #146's bedside and thought he would have taken them already. LPN #606 confirmed the medications in the cup were nine pills, resident's morning medications: - Cipro 500 milligrams (mg) - Carvedilol 25 mg - Vitamin D 1000u - Plavix 75 mg - Ferrous sulfate 325 mg - Hydralazine 50 mg - metformin 500 mg - senna 8.6 mg - venlafaxine extended release 150 mg LPN confirmed resident should have been monitored until he took all medications. Interview on 10/05/23 at 2:03 P.M. with MDS Nurse #239 revealed facility had no residents approved to self-administer pills/medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 45 of 47 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 10/10/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, staff interview and record review facility failed to ensure pureed foods were made to the correct texture and with following the recipe. This affected five Resident (#6, #25, #70, #74, and #88) with orders for pureed food. Facility census was 92. Findings include Observation and interview on 10/04/23 at 11:53 A.M. to 12:10 P.M. revealed Dietary staff #292 made puree food for five residents (Resident #6,#25,#70,#74, and #88). Dietary staff revealed she aimed for a mashed potato consistency for pureed food. She revealed for the rice she started a ½ cup scoop for each serving and made six servings with about ½ cup of water. She then added two tablespoon scoops of thickener. Dietary staff stated she thought this was a good consistency. Surveyor asked to do a taste test for texture and taste and dietary staff completed taste test and stated oh that tastes like paste. The texture was gummy and sticky with full grains of rice still present and visible. Dietary staff then added another ½ cup of water to loosen it up. She then blended the mixture and a second taste test was completed. Dietary staff confirmed rice mixture still had chunks of grains of rice and dietary staff revealed this was probably the best it would get and revealed she would serve it. The mixture was thick, sticky and had full grains of rice still present and required chewing. Through surveyor intervention dietary staff was asked to check with dietician and kitchen manager regarding the texture. Dietician #295 tasted the mixture and revealed it still had grains of rice and may be okay if gravy were added. Dietary Manager #289 did not taste the mixture but revealed facility would go ahead and substitute the pureed rice for instant mashed potatoes due to texture. Next the pork chop was pureed. Dietary staff revealed she was making six servings of three ounces each to have a little extra. The pork chop was cubed prior to being placed in the roboku blender and five servings of gravy were added (about 3 oz scoops each) and the mixture was blended. The mixture was tasted and dietary staff revealed it had chunks of meat present and had a texture of pulled pork/stringy. Two additional scoops of gravy were added and the mixture was blended again and retasted by dietary staff and surveyor. She confirmed mixture still had stringy/chunky texture but revealed she was comfortable serving it at this consistency. Dietary staff placed pork dish in warmer to reheat prior to service. Interview on 10/05/23 at 3:54 P.M. with Dietary staff #292, Dietary Manager #289 and Corporate Director of Nutrition Services (CDNS) #604 confirmed pureed consistency should be smooth and free of chunks of food. Dietary manager was not aware dietary staff was going to serve the rice prior to surveyor intervention, which dietary staff again confirmed. CDNS confirmed having chunks in pureed food was a choking hazard and surveyor explained role as surveyor was not to provide step by step instructions to staff when making pureed food. Dietary manager and dietary staff confirmed facility had recipes and those were not used of followed during observation. Review of the white rice puree revealed portion size of a ½ cup of with recipe for 50 serving sizes. The recipe included 200 ounces of rice and 1 quart of water with instructions to measure the desired number of servings in the food processor/blender and blend until smooth. Add water one cup at a time to moisten and add commercial thickener if needed. Review of pureed recipe for pork chop revealed the pork chop should be processed until fine consistency. Next, gradually add hot broth and thickener while processing. Staff should scrape sides with a food process/blender and reprocess. Consistency should be mashed potato consistency. Food should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 46 of 47 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 10/10/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete topped with gravy or barbeque sauce. The recommended amounts for five serving sizes included 15 ounces of pork chop and eight tablespoons of chicken broth. The recipe revealed the volume of liquid required may vary slightly depending on the texture of the product. The recipe also included one tablespoon of thickener but to start with none and then gradually add if needed. Review of facility policy titled Therapeutic Diets, dated 2017, revealed the facility would provide therapeutic diets and texture modified diets. The policy revealed support staff work under the Dietician but provided no information or guidance on how texture modified food items are made. Event ID: Facility ID: 365611 If continuation sheet Page 47 of 47