Inspection·March 27, 2024

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Effective [DATE], for new admissions, the admitting nurse would verify all orders with either the Medical Director or the on-call physician. If the new admission resident had a diagnosis of diabetes and the admitting nurse was not able to speak directly to the Medical Director, and the on call physician did not prescribe any form of diabetic monitoring, then the DON or the nurse manager on call, would review all orders with the Medical Director or Nurse Practitioner to ensure the resident's needs were being met and they have appropriate blood glucose monitoring orders. Residents Affected - Few • On [DATE], an Ad Hoc Resident Council meeting was held with the Activities Director #157, Administrator, and 13 residents (#9, #19, #21, #27, #44, #63, #75, #84, #85, #87, #100, #101, #106) to review updated standards of practice provided by the Medical Director, the facility following physicians' orders, and signs and symptoms of hypo/hyperglycemia. The residents present (some of whom were not diabetic) provided no additional feedback. All residents in the facility had been invited to discuss the updated standards of practice and provide feedback. • On [DATE], all staff were educated related to monitoring for signs and symptoms of hypo/hyperglycemia by the Director of Nursing/designee. The education was added to the new hire orientation agenda as of [DATE]. All staff were trained by [DATE]. • On [DATE], the DON/designee educated all nurses on the Medical Director's preferred standards for diabetic residents as well as following physician orders by the Director of Nursing/Designee. Agency staff would be educated upon their arrival for their scheduled shift. • On [DATE] from 1:30 P.M. to 2:39 P.M., a finger stick blood sugar was completed on all diabetic residents (#1, #2, #3, #4, #9, #10, #13, #14, #17, #31, #32, #34, #36, #43, #45, #47, #51, #52, #56, #59, #62, #64, #66, #68, #70, #72, #74, #78, #79, #80, #84, #85, #86, #92, #93, #94, #97, #102, #105 and #106). One resident (#49) refused the blood sugar check. The results were reported to the Medical Director/Nurse Practitioner and orders were received as indicated. All diabetic residents were assessed for signs and symptoms of hypoglycemia/hyperglycemia and their orders were reviewed by the Medical Director/Nurse Practitioner to ensure they had appropriate orders for blood glucose monitoring and blood glucose levels were being followed per physician orders. During this review, two residents (#99 and #105) were identified as receiving oral antihyperglycemic medication without orders for routine blood glucose monitoring. No new orders or changes were made at that time. • Beginning [DATE], an ongoing audit would be completed by the Director of Nursing/Designee daily for four weeks, then randomly thereafter. The audit would include ensuring all residents with diabetes had appropriate orders for monitoring blood glucose, ensuring nursing staff follow physician's orders, and staff were aware to identify and report symptoms of hypo/hyperglycemia. New admissions would be included in the audit and would be audited to ensure the Medical Director was notified and reviewed the chart, there were appropriate orders for blood glucose monitoring, and that staff were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0684 following the orders received by the Medical Director related to diabetic monitoring. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few Interviews on [DATE] from 1:13 P.M. to 1:30 P.M., with Registered Nurse (RN) #110, RN #214, Licensed Practical Nurse (LPN) #128, State Tested Nursing Assistant (STNA) #131, STNA #145, Dietary [NAME] #219, and Housekeeper #205 revealed the staff were knowledgeable of the signs/symptoms of hypo/hyperglycemia. Additionally, facility nurses were knowledgeable on the new admission/readmission process. • On [DATE], the facility obtained physician orders for Resident #99 and Resident #105, who were diabetic and required medication to treat for routine blood glucose monitoring. Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #104 revealed an initial admission date of [DATE] and discharge to an acute care hospital on [DATE] with diagnoses including diabetes mellitus, alcohol dependence induced acute pancreatitis, alcohol abuse, heart failure, and long-term use of insulin. Resident #104 was also hospitalized from [DATE] to [DATE] and from [DATE] to [DATE]. Following the [DATE] hospitalization, the resident did not return to the facility. Review of an acute care hospital Discharge summary, dated [DATE] (initial admission), revealed Resident #104 was discharged with an order for NPH insulin 70/30 (mixture of short and fast acting insulin) 100 units/milliliter (ml) with special instructions to administer eight units under the skin twice daily before meals. The order indicated vials should be rolled between palms of hands 10 times prior to each use and the insulin should be administered 30 to 40 minutes prior to the meal. Additionally, Resident #104 was discharge with an order for Dapagliflozin propanediol (oral medication used to lower blood glucose level) 10 milligrams (mg) by mouth daily for diabetes mellitus. Review of Resident #104's physician orders revealed an order, dated [DATE], for NPH insulin 70/30 100 units/ml with special instructions to administer eight units subcutaneously twice daily for diabetes mellitus, administer 30 to 40 minutes before meals, and included the vial should be rolled between palms of hands (prior to drawing up the insulin). The NPH insulin remained an active order until [DATE] when the order was discontinued. Further review of Resident #104's physician orders revealed no orders for routine blood sugar/glucose monitoring from [DATE] to [DATE]. Review of Resident#104's physician orders revealed an order, dated [DATE] for Dapagliflozin propanediol 10 mg by mouth daily for diabetes mellitus. Further review revealed the medication remained an active order until [DATE] when Resident #104 was readmitted from an acute care hospitalization. Review of Resident #104's vital sign documentation revealed a blood glucose level of 290 mg/deciliter (dl) was obtained by LPN #156 on [DATE] at 5:52 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the progress note, dated [DATE] at 11:35 P.M., revealed Resident #104 was confused and was not responding, vital signs were taken and recorded. Resident #104's blood sugar was taken and it was very low (actual value not documented). The on-call physician service was notified and gave an order to send the resident to the local emergency department (ED). 911 was called and the resident was sent to the local hospital. Review of the emergency medical service (EMS) run sheet, dated [DATE], revealed the facility called EMS at 9:42 P.M. and EMS arrived on the scene at 9:47 P.M. Upon arrival to the facility Resident #104 was found in bed with possible hypoglycemia. Resident #104's blood glucose was 31 mg/dl. Resident #104 was confused and slow to respond with some combative behaviors. EMS established intravenous (IV) access and dextrose (a sterile solution of sugar and water given IV to raise blood glucose level) was administered. The resident began to regain mental status. The facility staff present were unsure of the resident's baseline mental status. EMS completed a recheck of the resident's blood glucose and it was 186 mg/dl. The resident was transported to the local ED for further evaluation due to the hypoglycemic episode. Review of the acute care hospital summary, dated [DATE], revealed Resident #104 was transported to the local ED via medics. The summary revealed when the medics arrived to the facility the resident's blood glucose level had dropped even more to 31 mg/dl. The medics administered dextrose to the resident which raised the resident's blood glucose to 122 mg/dl upon arrival to the ED. The summary indicated Resident #104 alerted the emergency room physician of poor oral intake. Resident #104's blood sugar again began to drop and was in the 70's at which time the resident was given Dextrose 50 (D50). The resident's urinalysis was consistent with a urinary tract infection (UTI) and the resident was placed on a course of Keflex following a round of IV Rocephin (antibiotic medication used to treat infections). The final diagnoses given following the ED visit was hypoglycemia and acute cystitis without hematuria. Review of the progress note, dated [DATE] at 4:07 A.M., revealed Resident #104 returned to the facility at 3:45 A.M. with her son and two paramedics. The resident's vital signs were taken and were stable. The resident was in bed sleeping with the call light within reach. Review of Physician #113's progress note, dated [DATE], revealed the physician documented Resident #104's medication regimen, noted blood glucose trends and labs were reviewed, and to continue current medications, monitor blood glucose daily and adjust regimen as needed. The physician also indicated to check Hemoglobin A1C (HgbA1c), lipids and basal metabolic panel periodically. The note indicated a HgbA1c (lab which indicates the average glucose level over the past few months) was ordered. Review of Resident #104's medical record revealed Resident #104's blood glucose level was obtained by RN #220 on [DATE] at 11:24 A.M. and was 149 mg/dl as well as on [DATE] at 5:31 P.M. and was 200 mg/dl. Further review of Resident #104's medical record revealed no documented evidence the resident's blood glucose was monitored routinely following the instance of hypoglycemia leading to a transfer to the emergency department on [DATE] after this date. Review of Resident #104's comprehensive Minimum Data Set assessment, dated [DATE], revealed Resident #104 had no cognitive deficit. The assessment indicated Resident #104 received daily insulin injections. Review of the medication pass note, dated [DATE] at 5:40 P.M., revealed Resident #104's blood glucose was obtained by RN #114 and was 100 mg/dl. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident #104's lab results, dated [DATE], revealed Resident #104's HgbA1c level was high at 7.7% (normal range of 5.7-6.5%). Review of Resident #104's plan of care, dated [DATE], revealed the resident was at risk for hyper/hypoglycemia reactions, abnormal lab values and diabetic ulcers related to diabetes. Interventions included to give medications per physician orders and monitor for signs/symptoms of hypo/hyperglycemia: change in mental status, fatigue, change in vision, change in vital signs and increased urination, and increase in hunger or thirst. Review of the medication pass note, dated [DATE] at 8:05 A.M., revealed Resident #104's blood glucose was obtained by RN #114 and was 81 mg/dl. Review of the progress note, dated [DATE] at 5:25 P.M., revealed Resident #104's blood sugar was low at 43 mg/dl. The resident was given orange juice, milk, oral glucose and Gvoke (a subcutaneous, prefilled syringe injection used to treat severe hypoglycemia) prefilled syringe (PFS) one mg/0.2 ml subcutaneously (SQ). The resident's blood sugar increased to 49 mg/dl and finally to 100 mg/dl. Once the resident's blood glucose level began to rise, the resident was observed eating with no signs/symptoms of hypoglycemia. The on-call physician was made aware, and a new order was given to hold Resident #104's insulin on [DATE] at 8:00 A.M. Review of the progress note, dated [DATE] at 6:26 P.M., revealed Resident #104's blood glucose was 184 mg/dl following the injection of Gvoke PFS one mg/0.2 ml. Review of an EMS run report, dated [DATE], revealed the facility called 911 at 11:08 P.M. and alerted EMS of the need for emergency services for hypoglycemia with cardiopulmonary resuscitation (CPR) in progress. Upon entry at 11:19 P.M., the facility staff were observed performing chest compressions with Resident #104 making grunting sounds. EMS ordered the staff to stop compressions and a pulse was immediately identified in Resident #104's neck. The resident was responding to painful stimuli and the facility staff reported they had been doing chest compressions for approximately 10 minutes. EMS administered Dextrose 10 via IV and Resident #104 responded and had a blood glucose level of 48 mg/dl at 11:21 P.M. The report documented the resident's blood glucose level was 237 mg/dl at 11:35 P.M. The resident was transported to the local acute care hospital. Review of the progress note, dated [DATE] at 11:45 P.M., revealed Resident #104 was found unresponsive with a blood sugar of 39 mg/dl. The resident was unable to tolerate oral glucose so a Glucagon (medication used to raise blood glucose) SQ was administered. The resident's blood sugar was rechecked and had gone down to 36 mg/dl. The resident remained unresponsive with no pulse or breathing. The staff initiated cardiopulmonary resuscitation (CPR), called 911 and continued CPR until 911 arrived and took over. The resident was transported to a local hospital. Review of the progress note, dated [DATE] at 4:28 A.M., revealed a follow-up call was placed to the local hospital and the resident was being admitted to the hospital. No diagnoses was documented for the admission as of this time. Review of Resident #104's February 2024 Medication Administration Order (MAR) revealed Resident #104's NPH 70/30 insulin was scheduled to be administered at 8:00 A.M. and 4:30 P.M. Staff documented Resident #104 received the insulin at 8:00 A.M. and 4:30 P.M. Review of the facility mealtimes revealed the dinner meal cart was scheduled to be brought to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 100 hallway, where Resident #104 resided, at 6:30 P.M. which was approximately two hours following the scheduled administration time of 4:30 P.M. for the NPH 70/30 insulin, even though the order indicated to administer the insulin 30-40 minutes prior to the meal. Review of Resident #104's re-admission acute care hospital Discharge summary, dated [DATE], revealed the resident was admitted to the acute care hospital for hypoglycemia, hypotension, unresponsiveness, fractured clavicle and fractured right second rib. While at the acute care hospital, the resident's oral antihyperglycemic medication Dapaglifozin Propanediol 10 mg by mouth daily and NPH 70/30 insulin 100 units/ml were discontinued. The resident was ordered Glargine insulin 10 units subcutaneously daily at bedtime and Lispro Insulin 100 units/ml subcutaneously three times daily before meals per sliding scale as follows: 151-200 mg/dl administer two units, 201-250 mg/dl administer four units, 251-300 mg/dl administer six units, 301-350 mg/dl administer eight units, 351-400 mg/dl administer 10 units and call the physician if blood glucose level is less than 60 mg/dl or greater than 300 mg/dl. Interview on [DATE] at 11:50 A.M. with the DON revealed she was aware Resident #104 had no routine blood glucose level monitoring in place and would have expected to see physician orders for the resident's blood glucose level to be checked prior to administration of the insulin. Interview on [DATE] at 2:23 P.M., with Pharmacist #111, who was employed with the facility contracted pharmacy, revealed it was recommended with all insulin medications to routinely obtain a blood glucose level prior to the administration of the insulin, especially if the resident has had hypoglycemic episodes. Interview on [DATE] at 2:34 P.M. with Nurse Practitioner (NP) #112 revealed she does not verify the hospital admission orders and only Physician #113 can verify the orders coming from an acute care hospital. NP #112 revealed she reviewed Resident #104's blood glucose levels that were available in the electronic medical record. NP #112 revealed she spoke with Resident #104's family regarding Resident #104 not eating and requested the family to bring snacks to the facility for Resident #104. NP #112 revealed she thought Resident #104 had routine blood glucose level checks and verified the lack of physician orders for routine blood glucose level checks. Interview on [DATE] at 2:55 P.M. with Physician #113 revealed she was unaware Resident #104 did not have routine monitoring of blood glucose levels. Physician #113 revealed all residents admitted to the facility under her care with a diabetes mellitus diagnosis, regardless of whether they were on insulin or oral antihyperglycemic medication needed to have blood glucose monitoring. Physician #113 revealed diabetic residents should also have HgbA1c levels drawn periodically. Physician #113 verified Resident #104 should have had routine blood glucose monitoring in place with the use of the NPH 70/30 insulin and oral antihyperglycemic medication. Review of the Highlights of Prescribing Information, last revised [DATE], revealed NPH 70/30 is an insulin indicated to improve glycemic control in adults with diabetes mellitus. Individualize and adjust dosage based on metabolic needs, blood glucose monitoring and glycemia control goal. Hypoglycemia may be life-threatening. Monitor blood glucose and increase monitoring frequency with changes to insulin dosage, use of glucose lowering medications, meal pattern changes, physical activity, patients with hypoglycemia unawareness and acute illness. Further review revealed the NPH 70/30 insulin mean peak of lowering the blood glucose happens with one to five hours. Review of the facility policy titled, Blood Glucose Testing, dated [DATE], revealed the purpose of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0684 blood glucose testing was to monitor blood glucose control and assess for acute changes. Level of Harm - Immediate jeopardy to resident health or safety Review of the facility policy titled, Preparation and General Guidelines, last revised [DATE], revealed medications were to be administered within 60 minutes of the scheduled time, except before, with or after meal orders, which were administered based on mealtimes. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00152110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure their medication error did not exceed five percent. The facility had two medication errors out of 28 opportunities resulting in a medication error rate of 7.14 percent. This affected two (Resident #30 and Resident #36) of five residents reviewed for medication administration. The census was 102. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #30 revealed an initial admission date of 08/31/23 with diagnoses including dementia, cerebrovascular accident with right sided hemiplegia, asthma, severe protein-calorie malnutrition, multiple sclerosis, chronic obstructive pulmonary disease, anemia, metabolic encephalopathy, bipolar disorder, chronic pain, osteoarthritis, hypertension and major depressive disorder. Review of Resident #30's quarterly Minimum Data Set (MDS) assessment, dated 01/03/24, revealed Resident #30 had a moderate cognitive deficit. Review of Resident #30's monthly physician orders for March 2024 revealed an order, dated 01/30/24, for a Lidocaine patch four percent with the special instructions to apply to left knee topically daily for left knee for pain or stiffness and remove at bedtime. Observation on 03/19/24 at 9:06 A.M., of Registered Nurse (RN) #153 administering Resident #30's morning medication revealed RN #153 removed the Lidocaine four percent patch from Resident #30's left knee and the Lidocaine patch was dated 03/18/24. The RN then applied a Menthol five percent topical patch to Resident #30's knee. Interview on 03/19/24 at 9:20 A.M., with RN #153 verified the Menthol five percent patch was incorrectly administered to Resident #30. 2. Review of the medical record for Resident #36 revealed an initial admission date of 05/18/11 with the latest readmission of 10/07/19 with diagnoses including chronic obstructive pulmonary disease, senile degeneration of brain, Alzheimer's disease, hypertension, diabetes mellitus, chronic pain, anxiety disorder, cerebrovascular disease, hypertension, hyperlipidemia and congestive heart failure. Review of Resident #36's quarterly MDS assessment, dated 01/10/24, revealed Resident #36 had a moderate cognitive deficit. Review of Resident #36's monthly physician orders for March 2024 revealed an order, dated 07/06/23, for Levsin sublingual (SL) 0.125 milligrams (mg) with the special instructions to administer SL daily for drooling. Observation on 03/19/24 at 9:35 A.M., of RN #153 administering Resident #36's morning medication revealed she placed the Levsin 0.125 SL tablet in a plastic cup of pills with all of Resident #36's other ordered medications. Further observation revealed Resident #36 swallowed the Levsin 0.125 mg SL tablet instead of RN #153 placing the tablet under Resident #36's tongue to dissolve. Interview on 03/19/24 at 9:38 A.M., with RN #153 verified Resident #36's Levsin 0.125 mg medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 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 0759 was not administered by the ordered route. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Medication Administration-General Guidelines, last revised December 2019, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The five rights, right resident, right drug, right dose, right route and right time are applied to each medication being administered. A triple check of these five rights are recommended at three sets in the process of preparation of a medication for administration. When the medication is selected, when the dose is removed from the container and finally just after the dose is prepared and the medication put away. Residents Affected - Few This deficiency represents non-compliance investigated under Master Complaint Number OH00152110. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 9 of 9