Health inspection·June 30, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm behaviors prior to administering as-needed psychotropic medications for Resident #25. This affected two residents (Resident #22 and Resident #25) of five reviewed for antipsychotic medication administration. The facility census was 83. Findings include: Residents Affected - Few 1. Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 01/10/24 revealed Resident #22 requires use of psychotropic medications with potential for adverse reactions related to depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications per physician order and evaluating effectiveness and side effects for possible dose decrease or elimination of psychotropic drugs. Review of physician orders dated 01/19/25 revealed an order for olanzapine oral tablet 5 milligrams (mg) by mouth twice daily for agitation. Review of physician orders dated 05/10/25 revealed an order for olanzapine oral tablet 5 mg by mouth twice daily for major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 was cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. The resident was currently receiving antipsychotic, antianxiety, and antidepressant medications. Interview on 06/26/25 at 1:26 P.M. with Social Worker (SW) #195 confirmed olanzapine is not appropriate for treatment of major depressive disorder or agitation. Social Worker #195 stated the medication label for olanzapine indicates usage for bipolar disorder and schizophrenia, neither of which are active diagnoses for Resident #22. SW #195 confirmed bipolar which was listed as an active diagnosis was marked incorrectly on Resident #22 medical diagnoses. Review of the U.S. Food and Drug Administration (FDA) drug label for olanzapine revealed indications for treatment of schizophrenia, acute treatment of manic or mixed episodes associated with bipolar I disorder, and maintenance treatment of bipolar I disorder. Review of antipsychotic medication use policy dated 07/2022 revealed residents will only receive antipsychotic medications when necessary to treat specific condition for which they are indicated and effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 2 of 26 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 06/30/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure accurate coordination with the Pre-admission Screening and Resident Review (PASARR) process by submitting an incorrect list of mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for PASARR. The facility census was 83. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 08/21/23 revealed Resident #22 was at risk for changes in mood related to diagnoses of depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications as ordered, allowing time to express feelings, and encouraging participation in preferred activities. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 is cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. Review of the Pre-admission Screening and Resident Review (PASARR) dated 06/20/23 listed the following mental health diagnoses for Resident #22: mood disorder, panic or other severe anxiety disorder, unspecified anxiety disorder, post-traumatic stress disorder, major depressive disorder, and insomnia. Diagnoses of borderline personality disorder, other specified personality disorder, and bipolar disorder were not included. Interview on 06/25/25 at 3:48 P.M with Social Worker #195 confirmed the PASARR submitted on 06/20/23 did not include borderline personality disorder or other specified personality disorder. The social worker stated bipolar disorder was listed in error and would be removed from the resident's active diagnosis list. Social Worker #195 acknowledged a new PASARR would need to be submitted to the state mental health authority with the correct diagnoses, including borderline personality disorder and other specified personality disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 3 of 26 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 06/30/2025 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview, the facility failed to ensure the state mental health authority was notified of updated and accurate mental health diagnoses. This affected one resident (Resident #22) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR). The facility census was 83. Findings include: Review of the medical record for Resident #22 revealed an admission date of 08/12/22. The resident had documented mental health diagnoses including other specified personality disorder (07/11/17), bipolar disorder (11/24/17), borderline personality disorder (12/04/17), major depressive disorder (10/07/18), unspecified mood disorder (12/01/21), and both post-traumatic stress disorder and anxiety disorder (08/12/22). Review of the care plan dated 08/21/23 documented Resident #22 was at risk for changes in mood related to diagnoses of depression, anxiety, and post-traumatic stress disorder. Interventions included administering medications as ordered, allowing time to express feelings, and encouraging participation in preferred activities. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed Resident #22 was cognitively intact and had active psychiatric/mood diagnoses of anxiety disorder, depressive disorder, bipolar disorder, and post-traumatic stress disorder. Review of the Pre-admission Screening and Resident Review (PASARR) dated 06/20/23 listed the following mental health diagnoses: mood disorder, panic or other severe anxiety disorder, unspecified anxiety disorder, post-traumatic stress disorder, major depressive disorder, and insomnia. Diagnoses of borderline personality disorder and other specified personality disorder were not included. Interview on 06/25/25 at 3:48 P.M. with Social Worker #195 confirmed the resident's current diagnoses included borderline personality disorder and other specified personality disorder. The social worker stated bipolar disorder had been marked in error on the resident's diagnosis list and would be removed. Social Worker #195 acknowledged the PASARR submitted on 06/20/23 did not reflect all current and accurate diagnoses and stated a revised PASARR would need to be submitted to the state mental health authority. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 4 of 26 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 06/30/2025 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 interview and record review the facility failed to hold a timely admission care conference for one resident. This affected one resident (#188) of three residents sampled for care planning. The facility census was 83. Findings include: Review of Resident #188's medical record revealed an admission date of 06/03/25 and diagnoses including chronic obstructive pulmonary disease, cerebral infarction, atrial fibrillation, major depressive disorder, anxiety disorder, adjustment disorder with depressed mood, polyneuropathy, hypertension, antisocial personality disorder, and insomnia. Review of Resident #188's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #188 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. Further review revealed the resident had daily verbal behaviors directed at others and rejected care daily. Review of Resident #188's physicians' orders revealed an order for two staff members to be in his room for any care or contact dated 06/04/25. Review of Resident #188's medical record revealed no evidence of an admission care conference being held with Resident #188. In an interview on 06/23/25 at 9:47 A.M. Resident #188 stated that he had not had a care conference meeting since being admitted to the facility. In an interview on 06/25/25 at 8:56 A.M. the Administrator confirmed an admission care conference had not yet been held with Resident #188. The Administrator stated the care conference had been scheduled. In an interview on 06/25/25 at 10:45 A.M. the Administrator revealed a care conference was scheduled with Resident #188 on 06/26/25 from 12:30 P.M. to 1:00 P.M. Review of the policy titled Care Planning - Interdisciplinary Team (revised 03/2022) revealed the resident, resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. further review revealed that if it was determined that participation of the resident or the resident's representative was not practicable an explanation would be documented in the record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 5 of 26 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 06/30/2025 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 observation, resident interview, staff interviews, personnel file reviews, record review and policy review, the facility failed to ensure activities were offered to meet the individualized needs of a resident. This affected one resident (#48) of one resident reviewed for activities. The facility census was 83. Residents Affected - Few Findings Include: Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. She needed substantial assistance for bathing and personal hygiene and was dependent on staff for toileting, lower body dressing and transfers. Review of the care plan dated 10/14/24 revealed Resident #48 was capable of pursuing independent and group activities, that the goal for Resident #48 was to participate in 3-5 activities a week. Interventions on the care plan included: Encourage attendance and participation in activities, Invite resident to attend scheduled activities and provide assistance/escort to activity functions. The care plan also noted that resident was at risk for psychosocial well being concerns and an intervention suggested to enhance her well being was for staff to encourage involvement in activities. Review of the Activities Assessment for Resident #48 dated 04/18/25 revealed Resident #48 rated the following activities as very important: having books, newspapers and magazines to read; listening to music; doing things with groups of people; going outside when weather is good; and being around animals. Interview on 06/23/25 at 10:01 A.M. with Resident #48 said she is dependent on staff to help her get up to go to activities and they haven't been taking her. She said they do not bring activities for her to do in her bed and specified, not even a book. Observation on 6/24/25 at 1:52 P.M. confirmed resident had an activity calendar posted in her room on the wall out of her reach. Interview on 06/24/25 at 1:53 P.M. with Resident #48 revealed she likes to work with pastels but hasn't had the opportunity since she arrived at the facility. She would like to do word search and finds, jumbles or freestyle art. She said that these were not provided for her. She said she hadn't been to a facility activity in months. Interview on 06/25/25 at 8:32 A.M. with Activities Assistant #148 confirmed that while she is a trained aide and could assist with getting Resident #48 to an activity, she could not recall the last activity that was offered to Resident #48. She said they deliver the calendars and the newsletters to the room. She said she knows the resident likes bingo and reads articles on her phone. Interview on 6/25/25 at 1:33 P.M. with Activities Director #188 confirmed she is new in the role and she could not find any written documentation of when activities were offered to Resident #48. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 6 of 26 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 06/30/2025 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 also was unable to locate any documents that confirmed Resident #148's attendance at an activity in past three months. Review of personnel files for previous activities director confirmed previous activities director was terminated on 03/20/25. Residents Affected - Few Review of personnel file for current Activities Director #188 confirmed her enrollment in activities certification program was paid for on 06/25/25. Review of facility policy titled, Activities Evaluation noted activities assessment should be integrated into individualized care plan for residents and the activities are offered in a way that accommodates a resident's physical limitations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 7 of 26 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 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review revealed the facility failed to ensure a hand protector was in place for Resident #35 as ordered. This affected one resident (#35) of three residents reviewed for positioning and mobility. The facility census was 83. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting left side, type two diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. She had a range of motion impairment of upper and lower extremity on one side. Review of Resident #35's plan of care dated 10/29/24 revealed the resident required use of splinting palm protector of left hand. She was at risk for skin irritation and or breakdown contracture. Interventions included assessing splint or brace for defects, cleansing area of skin, and inspecting skin for irritation. Review of Resident #35's physician order dated 10/29/24 revealed an order for a hand splint palm protector to the left hand every shift. Observation on 06/24/25 at 10:45 A.M., 3:39 P.M., and 4:21 P.M., on 06/25/25 at 10:10 A.M., and on 06/26/25 at 7:49 A.M., 9:00 A.M., and 10:00 A.M. revealed Resident #35's palm protector was not in place. Interview on 06/26/25 at 10:05 A.M. Licensed Practical Nurse (LPN) #236 verified the protector was not in place, she searched the bedside table and was unable to find it. At 10:05 A.M. she reported she got a new palm protector to put in place. LPN #236 reported that the resident usually tolerates the splint well and does not refuse it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 8 of 26 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 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 ensure a complete investigation was completed to determine root cause analysis when a resident sustained a fall and failed to ensure fall safety interventions were in place as per residents care plan. This affected three residents (#238, #3, and #79) of the six residents reviewed for accidents and falls. Facility census was 83. Findings include: 1. Review of the medical record for Resident #238 revealed an initial admission date of 08/30/2023, a re-entry date of 11/20/2024 and a discharge date of 12/03/2024. Diagnoses included non-traumatic intracerebral hemorrhage, dementia, and hypertension. Review of Resident #238's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating an severely impaired cognition for daily decision making abilities. Resident #238 was noted to display behaviors including rejection of care. Resident #238 was noted to be free of any impairment to his upper and lower extremities and was noted to be independent with all activities of daily living and mobility. Review of Resident #238's admission Fall Risk assessment dated [DATE] revealed a score of 8 indicating this resident was at a low fall risk. Review of Resident #238's annual Fall Risk assessment dated [DATE] revealed this assessment was incomplete. Review of the progress note dated 11/08/2024 at 9:15 A.M. revealed Patient states he fell last night and ever since he is unable to move his right leg. Upon assessment patient's right hip and leg noted with some redness, unable to do range of motion, patient also noted crying during assessment. He usually walks around the facility but unable to even sit up at this time. Nurse Practitioner instructed nursing to transfer patient to the hospital for further evaluation. Continued review of Resident #238's medical records revealed no evidence to support that a post fall investigation was completed or if this reported fall was reviewed. Interview on 06/26/2025 at 3:00 P.M. with Regional Nurse #252 confirmed Resident #238's annual Fall Risk Assessment was incomplete as well as confirming a fall investigation was not completed for the reported fall that was said to have occurred on 11/07/2024 reported by the the resident. Review of the facility policy titled Falls Clinical Policy, revised 03/2018 revealed For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the cause of the fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction, or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. 3. Review of the medical record for Resident #79 revealed an admission date of 05/28/25, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 9 of 26 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 06/30/2025 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 diagnoses including chronic respiratory failure, hypertension, dissection of the ascending aorta, cerebral infarction, history of transient ischemic attack, metabolic encephalopathy, hemiplegia, and hemiparesis. Review of the hospital Discharge summary, dated [DATE], revealed activity instructions indicating that a helmet should be used during resident transfers and when the resident was out of bed. Residents Affected - Few Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 06/04/25, revealed Resident #79 was severely cognitively impaired and dependent on staff for all activities of daily living and ambulation. Observation on 06/23/25 at 9:21 A.M. revealed Resident #79 was seated in a recliner, engaged with staff, and wearing a protective head cap during the encounter. Review of the medical record on 06/23/25 showed no documentation specifying the requirement, frequency, or circumstances for wearing head protection. Observation on 06/24/25 at 7:32 A.M. revealed signage in Resident #79 ' s room, located behind the television, stating, STOP NO BRAIN FLAP ON LEFT SIDE. At that time, Resident #79 was lying in bed without the protective head cap. Interview on 06/26/25 at 2:11 P.M. with Registered Nurse #194 confirmed information about the indication and frequency for the use of the protective head covering should be documented either in the care plan or in physician orders. Interview on 06/26/25 at 2:14 P.M. with Assistant Director of Nursing (ADON) #146 confirmed that neither the care plan nor the physician's orders included documentation about the indication, frequency, or rationale for the use of the protective head cap. ADON #146 acknowledged that this information was only added after surveyors requested clarification, and that prior to the request, there was no system in place to ensure staff had consistent guidance on the use of head protection for Resident #79. This deficiency represents non-compliance investigated under Complaint Numbers OH00164069, OH00163718. 2. Review of Resident # 3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physicians orders dated 05/30/25 revealed no orders for fall interventions. Review of Resident #3's fall risk care plan dated 11/01/24 to 09/16/25 revealed fall interventions for a low bed, initiated on 02/03/25 and a fall mat to the right side of the bed when resident is in bed, initiated on 04/18/25. Observation on 06/23/25 at 10:20 A.M. revealed Resident # 3 in bed with the bed up in high position and fall mat folded up against the wall near her bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 10 of 26 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 06/30/2025 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 Interview on 06/23/25 at 10:25 A.M. with Licensed Practical Nurse (LPN) # 152 revealed Resident #3 was a fall risk and confirmed that the low bed with fall mat was not in place. 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 11 of 26 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 06/30/2025 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 interview, observation, and record review the facility failed to timely or accurately implement nutrition recommendations for Resident #13, #35, and #81. This affected three residents (#18, #35, #81) of seven residents reviewed for nutrition. The facility census was 83. Residents Affected - Few Findings include: 1. Review of Resident #18's medical record revealed an admission date of 09/25/21 with diagnoses including malignant neoplasm of mouth, dysphagia, protein-calorie malnutrition, adult failure to thrive, major depressive disorder (8/16/24), and unspecified psychosis. Review of Resident #18's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderately impaired cognition. Review of Resident #18's plan of care dated 03/24/25 revealed the resident had altered nutritional status as evidenced by impaired chewing ability, decreased intake of solids, refuses to eat puree and only drinks. The resident required tube feeding and supplement use. Her weight loss was unavoidable due to cancer status, refusal of tube feed, supplements, and meals. Interventions included administering medications as ordered, communicating with residents and family, diet as ordered, encouraging adequate fluid and oral intake, monitoring weight monthly and as needed, obtaining and monitoring lab work as ordered, providing supplements and tube feed as ordered, SLP as ordered. Review of Resident #18's physician order dated 03/28/25 to 05/22/25 revealed an order for Jevity 1.5 360 milliliters (ml) three times a day. Review of Resident #18's progress note dated 05/21/25 revealed the dietitian recommended increasing bolus feedings to four times a day. Review of Resident #18's physician order dated 05/22/25 to 06/13/25 revealed an order for Jevity 1.5 three times a day. Review of Resident #18's physician order dated 06/16/25 revealed an order for Jevity 1.5 bolus feeding four times a day 300 ml. Interview on 06/25/25 at 4:16 P.M. with Diet Technician #255 verified the recommendations from 05/21/25 were not put in place until 06/16/25. Interview on 06/26/25 at 2:04 P.M. with Dietitian #254 revealed ideally the facility would implement nutrition recommendations within 24 hours. She verified the tube feeding was not appropriately addressed in a timely manner and was not done correctly initially. 2. Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting left side, type two diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 12 of 26 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 06/30/2025 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 Review of Resident #35's plan of care dated 01/13/24 revealed the resident required tube feeding to assist the resident in maintaining or improving nutritional status related to dysphagia and history of poor intake. Interventions included alternate tube feeds with oral feeding as tolerated, check residual, maintain tube, monitor for complications, monitor for signs of aspiration Review of Resident #35's plan of care dated 04/04/25 revealed the resident had altered nutritional status as evidenced by need for mechanically altered diet with swallowing difficulty, need for assistance with meals. Interventions included administering medications as ordered, diet according to dietitian, feeding at meals, monitoring weight monthly, obtaining and monitoring lab work as ordered, tube feeding and flushes as ordered. Review of Resident #35's physician order dated 03/28/25 revealed an order for Glucerna 1.5, 80 ml an hour continuously starting at 8:00 P.M. and running until 720 mls have been infused. With the tube feed being turned off at 8:00 A.M. Review of Resident #35's progress note dated 03/28/25 revealed a recommendation to increase the residents tube feeding from 60 ml an hour to 80 ml an hour. Observation on 06/26/25 at 7:49 A.M. revealed Resident #35's tube feeding was running at 60 ml an hour. Interview on 06/26/25 at 7:55 A.M. with Licensed Practical Nurse (LPN) #236 verified the tube feed was running at 60 ml an hour as her tube feeding had been decreased to this rate. She reported this was what it was normally running at. Interview on 06/26/25 at 2:04 P.M. with Dietitian #254 revealed ideally the facility would implement nutrition recommendations within 24 hours. Dietitian #254 reported the 720 ml should have been removed from Resident #35's physician order since this indicated a tube feed rate of 60 ml an hour. 3. Review of the medical record for Resident #81 revealed an admission date of 04/19/25 with diagnoses including urinary tract infection, severe protein-calorie malnutrition, chronic kidney disease, and cognitive communication deficit. Review of the nutritional risk assessment dated [DATE] showed the resident was borderline underweight and required increased metabolic support for wound healing. Review of the admission Minimum Data Set (MDS) 3.0 completed on 04/26/25 showed the resident was severely cognitively impaired, required supervision or limited assistance with eating, and had a diagnosis of malnutrition. Review of a physician order dated 04/29/25 showed ProSource oral liquid nutritional supplement to be given 30 milliliters by mouth two times a day. Review of the care plan dated 05/02/25 revealed the resident had a diagnosis of protein-calorie malnutrition with interventions to allow time for meal consumption, assist with meals and fluids, encourage adequate nutrition and hydration, and provide diet, supplements, and vitamins/minerals as ordered by the physician. Review of the resident's weight history showed on 05/04/25, the resident weighed 122.8 pounds. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 13 of 26 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 06/30/2025 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 06/20/25, the weight was documented as 110.2 pounds, reflecting a 10.26% loss over approximately six weeks. Review of the nutrition progress note dated 06/20/25 showed a recommendation to increase the ProSource supplement from two times a day to three times a day in response to the documented weight loss. Residents Affected - Few Interview on 06/26/25 at 2:05 P.M. with Dietitian #254 confirmed the recommendation to increase ProSource oral liquid from two times a day to three times a day was made on 06/20/25 due to significant weight loss. The dietitian stated facility staff are expected to implement nutrition recommendations within 24 hours unless contraindicated or otherwise directed by the physician. Dietitian #254 confirmed the recommendation had not been implemented at the time of interview and was unaware of any documented reason for the delay. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 14 of 26 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 06/30/2025 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, policy review, and record review the facility failed to identify and make staff aware of trauma triggers for a resident with post-traumatic stress disorder and failed to provide consistent psychosocial intervention. This affected one resident (#45) of one sampled for mood and behavior. The facility census was 83. Residents Affected - Few Findings include: Review of Resident #45's medical record revealed an admission date 12/07/23 and diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, hyperlipidemia, anemia, intervertebral disc replacement lumbar region, spinal stenosis, major depressive disorder, post-traumatic stress disorder, hypertension, and heart failure. Review of Resident #45's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. Review of Resident #45's physicians' orders revealed the resident was receiving the antidepressant medications Zoloft 150mg daily, trazodone 100 mg daily at bed time, and Wellbutrin 150mg daily. Review of Resident #45's care plan for trauma revealed resident #45 was a trauma survivor and experienced anxiety and fear related to her past trauma. Further review revealed the resident was to be provided psychiatric services as requested by the resident and as recommended by her psychiatric providers, consultation with pastoral care, social services, psychosocial and behavioral support as needed and was to be provided psychosocial support services. Further review of Resident #45's care plan revealed no mention of specific triggers that may cause re-traumatization of the resident. Review of Resident #45's medical record revealed a social service admission assessment dated [DATE] revealed the facility identified Resident #45 as a trauma survivor but did not identify Resident #45's specific triggers that may lead to re-traumatization. Review of Resident #45's medical record revealed a quarterly social history review dated 03/10/25 and a quarterly social history review dated 05/15/25 with no indication of Resident #45's specific triggers that may lead to re-traumatization revealed in either review. Review of Resident #45's psychiatric progress notes provided by the facility revealed the resident is a client of GuideStar Eldercare, LLC psychiatric services. Further review of Resident #45's psychiatric notes revealed notes for 01/30/25, 02/27/25, 04/04/25, 04/10/25, 04/30/25, 05/01/25, 05/02/25, 05/29/25 and 06/13/25. The notes contained no mention of Resident #45's specific triggers that may lead to re-traumatization. Review of Resident #45's medical record revealed no documentation of the resident requesting counseling services. In an interview on 06/26/25 at 9:32 A.M. Resident #45 stated her triggers are loud noises, arguing or the perception of arguing, someone moving too fast around her or someone appearing suddenly in front of her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 15 of 26 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 06/30/2025 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/26/25 at 1:30 P.M. the Administrator and Social Worker #195 confirmed the facility had not identified Resident #45's triggers and had not identified them on the resident's care plan so the facility staff would be aware of the resident's triggers. In an interview on 06/26/25 at 2:41 P.M. Resident #45 stated she had asked for counseling from several people but does not recall when she asked. Resident #45 stated she would like to get counseling for at least six months and longer if the counselor feels she should continue. Resident #45 stated that she has been a victim of abuse since her childhood. Resident #45 further stated that a couple of weeks ago a facility staff member appeared suddenly in front of her causing her to jump and her heart to race for just a short amount of time. She stated that she also has nightmares about her past trauma. Resident #45 stated she assumes she is not getting counseling because the facility thinks that she does not need it. In an interview on 06/26/25 at 3:20 P.M. Social Worker #195 stated GuideStar Eldercare, LLC psychiatric services, the facility's behavioral provider, saw Resident #45 once a week. Although she stated there was a gap of about a week and half when there was a change in the provider. Social Worker #195 stated Resident #45 would be seen by the psychiatric provider for 20 minutes to an hour depending upon the residents willingness. Social Worker #195 confirmed the psychiatric progress notes provided by the facility covered the past three months. Review of the policy titled Trauma Informed Care and Culturally Competent Care, revised 08/2022, revealed assessment of trauma survivors should include the identification of triggers and the care plan should identify and decrease exposure to triggers that may re-traumatize the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 16 of 26 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 06/30/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and facility policy review, this facility failed to ensure controlled substances were logged or signed out in the control substance log when that medication was administered. This affected one resident (Resident #44) of the four residents reviewed during medication administration observation. The facility census was 83. Findings include: During observation completed on 06/26/2025 at 12:45 P.M. of one of the facility's four medication carts, it was noted that not all controlled substance medications were logged when the medication was removed from it packet for administration. Resident #44 was noted to have a package housing 12 tablet of the controlled substance, Lacosamide (Vimpat) 50 milligrams (mg), give one tablet two times a day. Review of the controlled substance log book for this medication cart revealed the last tablet signed out was on 06/25/2025 leaving 13 tablets Interview on 06/26/2025 at 12:48 P.M. with Licensed Practical Nurse (LPN) #112 revealed she administered one of the Vimpat tablets this morning to Resident #44 but did not sign the medication out or log the medication in the controlled substance log book. LPN #112 confirmed when a controlled substance is administered, the administering nurse is required to sign the log book to help verify this medication was removed from the package and to help keep count of how many tablets have been administered and how many tables remain. Review of facility policy titled Controlled Substances, revision date of 11/2022 revealed The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: Records of personnel access and usage, medication administration records, declining inventory records, and destruction, waste and return to pharmacy records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 17 of 26 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 06/30/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #3's medical record revealed that she was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 with foot ulcer and chronic kidney disease, malnutrition, paraplegia, discitis, borderline personality disorder and chronic pulmonary obstruction. She was alert and oriented. Review of Resident #3's clinical physician orders dated 05/30/25 revealed orders for Aspirin Oral Tablet Chewable 81 MG; give 1 tablet by mouth one time a day for hypertension, Insulin Glargine Subcutaneous Solution 100 UNIT/ML; inject 12 unit subcutaneously at bedtime for type 2 diabetes, Hydrochlorothiazide Tablet 25 MG; give 1 tablet by mouth one time a day for hypertension and edema, Ramelteon Oral Tablet 8 MG; give 1 tablet by mouth at bedtime for Insomnia and Gabapentin Capsule 400 MG; give 1 capsule by mouth three times a day for nerve pain. Review of Pharmacy Medication reviews from May 2024 to May 2025 for Resident #3 revealed no reviews for the months of July 2024, August 2024, September 2024, December 2024 and March 2025. Interview on 06/25/25 at 2:00 P.M. with Regional Director of Clinical Services (RGCS) and Director of Nursing (DON) revealed that the facility identified that the documentation was missing in March 2025 and did a plan to correct it at that time. The deficient practice was corrected on 03/25/25 when the facility implemented the following corrective actions: On 03/25/25 the facility requested pharmacy recommendations and forwarded them to the physician for review of current residents. On 03/25/25 the DON reviewed all current residents, ensuring that no deviations from their normal baselines were noted. On 03/25/25 all licensed staff were re-educated on the importance of forwarding pharmacy recommendations to the residents' provider for review. Random audits were performed on 03/28/25, 04/04/25, 04/11/25 and 04/18/25 and revealed no issues. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review and policy review, the facility failed to provide evidence of medication regiment reviews and pharmacy recommendations for Residents #3, #6 and #48. This affected three residents (#3, #6, #48) of five residents reviewed for pharmacy recommendations. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/16/22. Pertinent diagnoses included: acute and chronic respiratory failure with hypoxia, dementia, bipolar disorder, insomnia, and long term (current) use of anticoagulants. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 18 of 26 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 06/30/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan for Resident #6 dated 01/10/24 revealed Resident #6 required use of psychotropic medications with potential for adverse reactions related to Bipolar and associated mood disorder. An accompanying intervention recommendation stated that the resident (#6) should be monitored for effectiveness and side effects for possible decrease or elimination of the medication. Review of physician orders for Resident #06 revealed Resident #06 had order dated 06/01/23 for Sertraline HCI Tablet 100 milligrams (MG) to be given one time a day for depression related to bipolar disorder; an order dated 06/01/23 for trazodone HCI Oral Tablet 50 MG to be given one time a day for insomnia due to depression, an order dated 06/01/23 for Eliquis oral tablet 5 MG to prevent blood clots. Review of pharmacy documentation of review of medications for Resident #6 reveal no pharmacy recommendations or documentation of pharmacy review of medications for Resident #6 for December 2024 or March 2025. 2. Review of the medical record for Resident #48 revealed an admission date of 10/07/24. Pertinent diagnoses included: chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, chronic diastolic (congestive) heart failure, personal history of pulmonary embolism, schizoaffective disorder and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #48 had moderate cognitive impairment. She needed substantial assistance for bathing and personal hygiene and was dependent on staff for toileting, lower body dressing and transfers. Review of the care plan for Resident #48 dated 10/18/24 revealed Resident #48 required use of psychotropic medications with potential for adverse reactions related to anxiety, depression and schizophrenia. An accompanying intervention recommendation stated that the resident (#48) should be monitored for effectiveness and side effects of antidepressant medication. Review of the physician orders for Resident #48 revealed prescriptions including but not limited to: an order dated 04/11/25 for Ariprazole (antipsychotic) oral tablet 30 MG to be given one time a day for Schizoaffective Disorder; order dated 04/11/25 for Apixaban 2.5 MG to be given two times a day for blood clot; an order dated 4/11/25 Clonazepam tablet 1 MG to be given two times a day for anxiety. Review of the pharmacy recommendations and pharmacy documentation of no recommendations for the past 12 months for Resident #48 revealed absence of pharmacy documentation for Resident #48 for December 2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 19 of 26 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 06/30/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, record review, policy review and safety data sheet review, the facility failed to ensure Resident #38 was free from significant medication errors. This affected one resident (#38) of one resident reviewed for medication errors. The facility census was 83. Residents Affected - Few Findings Include: Record review revealed Resident #38 was admitted to the facility on [DATE]. Pertinent diagnoses included: type 2 diabetes mellitus with hyperglycemia, long term (current) use of insulin, acquired absence of right foot, acquired absence of left leg below knee, severe obesity and dementia. Review of quarterly Minimum Data Set (MDS) dated [DATE] for Resident #38 revealed he was cognitively intact. The functional assessment rated Resident #38 as independent on eating, hygiene, dressing and transfers, with supervision needed for showers/bathing. Review of Care Plan for Resident #38 dated 11/13/24 revealed Resident #38 was at risk for hyper/hypoglycemic reactions, abnormal lab values and diabetic ulcers due to his diabetes. Interventions for this focus suggested that medications should be given per physician order and that nursing should monitor for signs and symptoms of hypo/hyperglycemia (high/low blood sugar). Interview on 06/23/25 at 11:32 AM with Resident #38 who said nursing staff doesn't give his insulin to him in a timely manner. He said when he asks them they ignore him. He said he sometimes feels lightheaded. Review of physician's orders for Resident #38 revealed an order dated 11/04/24 for HumaLog Solution 100 unit/ml (fast acting insulin) to be injected subcutaneously before meals per sliding scale as follows: If blood sugar is 0 to 150, give 0 units. If blood sugar is 151 to 200, give 2 units. If blood sugar is 201 to 250, give 4 units. If blood sugar is 251 to 300, give 6 units. If blood sugar is 301 to 350, give 8 units. If blood sugar is 351 to 400, give 10 units. If blood sugar is greater than 400, call provider. Additionally, there was a physician order dated 11/23/24 for Resident #38 for Lantus (long acting insulin) SoloStar Solution Pen Injector for 25 units to be injected subcutaneously one time per day. Resident #38 had physician order dated 01/27/25 for Basaglar (long acting) Kwikpen Solution Pen-Injector 100 unit/ML (Insulin Glargine) 30 units to be injected subcutaneously at bedtime for diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 20 of 26 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 06/30/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/24/25 at 2:01 P.M. with Resident #38 shared he did not receive his medications the previous evening. He said he told the nurse and she just walked away. Review of Medication Administration Record (MAR) for Resident #38 for 06/23/25 appeared to confirm that Resident #38 did not receive his evening insulin medication (Basaglar), although the documentation indicated that he had refused the medication on the evening of 6/23/25. Further review revealed that the 6/22/25 scheduled 7:00 P.M. long acting insulin dose was documented as having been administered on 06/23/25 at 3:08 A.M. The documentation further indicated that on 06/23/25, less than five hours later, Resident #38 received his morning short acting insulin dose at 8:36 A.M. as well as his morning dose of long acting insulin at 8:39 A.M. Resident #38 had a recorded blood sugar of 214 at that time and he was administered 4 units of the short acting insulin. Per the MAR documentation, the resident was not available in the afternoon of 06/23/25 and there was no recorded blood sugar that day until 4:24 P.M. when the resident's blood sugar was 283 and he was administered 6 units of insulin. Interview on 06/24/25 at 3:02 PM with Registered Nurse (RN) #122 verified that the MAR indicated Resident #38 received his 6/22/25 evening dose of long acting insulin at 03/23/25 at 3:08 A.M. RN #122 said that if the medication is scheduled at bedtime you want to make sure you give it at the time the resident goes to bed. She said she does not look at previous evening's MAR and therefore would not know a resident received the bedtime dose in the early morning. She said Resident #38 does go out sometimes (in daytime) and that if he was gone at the time he should have received his insulin and he returned near dinner time, she would hold off on the dose. Interview on 06/24/25 at 4:40 PM with the Director of Nursing (DON) verified the MAR indicated Resident #38 received his 06/22/25 evening dose of insulin the following morning at 3:08 A.M. The DON said the bedtime administration of insulin could be variable if the resident goes to bed at different times. The DON said he was not concerned with the dose being administered so late because he said the blood sugar test would've caught any issues. Regarding the missed insulin dose on the evening of 06/23/25, he said that perhaps the resident was out of the building. Interview on 06/24/25 at 5:05 PM with Regional Director of Clinical Services #252 confirmed an order for bedtime medication administration should be given between the hours of 7:00 P.M. and 11:00 P.M. He verified the MAR record appeared to indicate the 06/22/5 evening dose of insulin was administered on 06/23/25 at 3:08 A.M. and confirmed that time was outside the accepted parameters. Interview on 06/25/25 at 9:10 A.M. with Resident #38 confirmed he did not leave the property on the evening of 06/22/25. He admitted he had been outside the dining room at the smoking area with other residents. He said he thought he came in around 10:00 or 11:00 P.M. He said he did not remember what time he received the 06/22/25 evening dose of insulin and said he did not refuse his insulin the evening of 06/23/25 and had not left the building that night either. Interview on 06/25/25 at 3:29 P.M. with the DON who said he spoke with the nurse who administered the insulin dose that was recorded at 3:08 A.M. on 6/23/25. He said that she relayed she was having internet troubles and had administered the dose earlier. He said she did not record the actual administration time on paper and he said there were no other residents who had late medication administration charted. Further review of the May and June 2025 MAR for Resident #38 revealed the evening administration of Basaglar was documented as being administered outside of the 7:00 P.M. to 11:00 P.M. time frame on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 21 of 26 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 06/30/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following dates: 05/10/25 at 1:31 A.M., 05/13/25 at 11:44 P.M., 05/15/25 at 5:39 A.M., 05/20/25 at 11:21 P.M., 05/23/25 at 11:31 P.M., 05/30/25 at 11:29 P.M., 06/06/25 at 11:51 P.M., and 06/09/25 at 11:28 P.M Review of facility policy titled, Administering Medications revised April 2019 stated medications are administrated in accordance with prescriber orders including any required time frame. Medication should be administered within one hour of prescribed time unless otherwise specified such as after meals. The policy stated that if resident is not in room or otherwise unavailable, the MAR may be flagged and the nurse will return to administer the dose. Review of the Safety Data Sheet for Bagaslar Insulin pen revised 07/2021 emphasized the importance of administering the medication at the same time every day. The safety data sheet stated that the median time to maximum effect of the medication is 12 hours. The data sheet warned that the risk for hypoglycemia is highest when the glucose lowering effect of the insulin is maximal and noted that changes in administration can increase risk. The safety data sheet also noted that symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes. This deficiency represents non-compliance investigated under Complaint Number OH00164069. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 22 of 26 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 06/30/2025 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. Based on observation, staff interview, and facility policy review, this facility failed to ensure medication stored in the medication room and medication carts were properly labeled with an open date. This affected two residents (#33 and #243) of the four residents reviewed during medication administration. The facility census was 83. Findings include: 1. Observations completed on 06/26/2025 at 12:30 P.M. of one of the facility's two medication rooms revealed one open box with a bottle of Humulin R 3 milliliter (ml) insulin in it. The open box was noted to belong to Resident #243 who no longer resided in this facility. No open date was noted on this box. The insulin bottle stored in the box was noted to have the metal cap removed from the top of the bottle. The insulin bottle did not have an open date on it. Interview on 06/26/2025 at 12:35 P.M. with Licensed Practical Nurse (LPN) #112 confirmed there was a box of insulin with no open date being stored in the refrigerator in the medication room. LPN #112 confirmed this medication should have been dated with it was opened to ensure it is discarded within the appropriate time frame. 2. Observation completed on 06/26/2025 at 12:37 P.M. revealed during observation of two of the facility's four medication carts a bottle of Artificial Tears belonging to Resident #33 with no open date. Interview on 06/26/2025 at 12:40 P.M. with LPN #112 confirmed this bottle of Artificial Tears had been opened with no open date noted. Review of the facility policy titled Medication Labeling and Storage (no date) noted revealed Multi-dose vials that have been opened or accessed (needle punctured) are dated and discharged within 28 days unless the manufacturer specified a shorter or longer date for the open vial. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 23 of 26 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 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete physician ordered lab tests. This affected one resident (#79) of three residents reviewed for lab tests. Findings include: Review of the medical record for Resident #79 revealed an admission date of 05/28/25, with diagnoses including chronic respiratory failure, hypertension, dissection of the ascending aorta, cerebral infarction, history of transient ischemic attack, metabolic encephalopathy, hemiplegia, and hemiparesis Review of the hospital discharge instructions dated 06/06/25 showed a requirement for a routine urine aerobic culture as part of pre-operative testing for a surgical procedure scheduled on 06/26/25. The discharge documents included a checklist for laboratory tests to be completed following transfer to the facility for a procedure. Review of the Minimum Data Set (MDS) dated [DATE] showed the resident was severely cognitively impaired, required extensive assistance for activities of daily living and is always incontinent of bowel and bladder. Review of physician orders dated 06/23/25 through 06/24/25 showed a one-time order for a urine culture and sensitivity. Review of the laboratory report dated 06/23/25 showed the test was canceled with the note Specimen not collected - nurse to order. No documentation showed any follow-up, reordering, or explanation for the cancellation. Review of the Medication Administration Record (MAR) for June 2025 showed the urine culture was scheduled for collection on 06/24/25 at 5:38 A.M. The entry was marked with code 5, which referred to a nurse's note. Review of progress notes from 06/23/25 and 06/24/25 showed no documentation of specimen collection, reason for hold, or contact with the physician. Review of care plan dated 06/26/25 revealed it did not include documentation of behavioral resistance, lab collection issues, or communication needs related to specimen collection. Interview with the Administrator and Director of Nursing on 06/25/25 at 9:46 A.M. revealed the resident refused urine specimen collection; however, nursing staff did not document the refusal. Instead, staff marked the test as completed and did not notify the physician of the refused specimen collection. The Director of Nursing and Administrator acknowledged no documentation existed to support resident refusal or staff communication regarding the canceled lab. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 24 of 26 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 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to ensure resident medical records contained information related to a resident's hospital admission. This affected one resident, (#238) of the six residents reviewed for accidents and falls. Facility census was 83. Findings include: Review of the medical record for Resident #238 revealed an initial admission date of 08/30/2023, a re-entry date of 11/20/2024 and a discharge date of 12/03/2024. Diagnoses included non traumatic intracerebral hemorrhage, dementia, and hypertension. Review of Resident #238's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 out of 15 indicating a severely impaired cognition for daily decision making abilities. Resident #238 was noted to display behaviors including rejection of care. Resident #238 was noted to be free of any impairment to his upper and lower extremities and was noted to be independent with all activities of daily living and mobility. Review of the progress note dated 11/08/2024 at 9:15 A.M. revealed Patient states he fell last night and ever since he is unable to move his right leg. Upon assessment patients right hip and leg noted with some redness, unable to do range of motion, patient also noted crying during assessment. He usually walks around the facility but unable to even sit up at this time. Nurse Practitioner instructed nursing to transfer patient to the hospital for further evaluation. Review of Resident #238's documentation revealed no evidence to support this resident was admitted to the hospital from [DATE] through 11/20/2024 for evaluation and treatment. Interview on 06/26/2025 at 3:00 P.M. with Regional Nurse #252 confirmed Resident #238's medical records did not contain information related to the resident's 12 day hospital stay from 11/08/2024 through 11/20/2024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 25 of 26 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 06/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westerville Post Acute. 1060 Eastwind Drive Westerville, OH 43081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure enhanced barrier precautions were maintained during skin care. This affected one resident (#35) out of 16 residents on enhanced barrier precautions. The facility census was 83. Residents Affected - Few Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/18 with diagnoses including hemiplegia and hemiparesis affecting the left side, type 2 diabetes mellitus, aphasia, hypertension, dysphagia, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #35's physician order dated 06/17/25 revealed an order for treatment of moisture-associated skin damage to the back of the head. Staff were instructed to cleanse the area with soap and water daily and as needed, pat dry, and leave open to air. Review of physician order dated 02/18/25 required enhanced barrier precautions for high-contact care, including dressing changes, requiring staff to wear a gown and gloves. Observation on 06/25/25 at 10:04 A.M. of moisture-associated skin damage care by Licensed Practical Nurse (LPN) #236 and Certified Nursing Assistant (CNA) #101 revealed both staff members touched the resident's blanket, remote, pillow, and head upon entering and throughout the care. LPN #236 and CNA #101 introduced themselves and gathered catheter supplies. Enhanced barrier precautions (EBP) signage was posted on the door. However, neither staff member donned Personal Protective Equipment (PPE) while providing direct care. When asked about the signage, staff stated it applied to the neighboring resident and that PPE was not required for Resident #35. Interview on 06/26/25 at 2:54 P.M. with the Director of nursing (DON) confirmed Resident #35 had current orders for enhanced barrier precautions during care, which includes the use of gowns and gloves when providing care involving high-contact areas. The DON also confirmed that both LPN #236 and CNA #101 should have worn appropriate personal protective equipment (PPE), specifically gowns and gloves, while performing moisture-associated skin damage (MASD) skin care due to the placement of Resident #35's feeding tube. Review of enhanced barrier precautions signage, undated, revealed everyone must, clean their hands, including before entering and when leaving the room and providers and staff must also wear gloves and a gown for high-contact resident care activities which includes dressing, bathing/showering, changing linens, providing hygiene and wound care (any skin opening requiring a dressing). Review of the Enhanced Barrier Precautions policy, dated December 2024, revealed enhanced barrier precautions are implemented to prevent the transmission of multi-drug resistant organisms (MDROs) to residents during high-contact care activities. The policy specifies that this is achieved by wearing gowns and gloves during such care. This deficiency represents non-compliance investigated under Complaint Number OH00166198. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365611 If continuation sheet Page 26 of 26