Inspection·May 8, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the medication error rate was less than five percent, as evidenced by three medication errors out of 31 opportunities observed, resulting in 9.68 percent (%) medication error rate. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Residents Affected - Few Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365621 If continuation sheet Page 2 of 5 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 365621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillsboro Post Acute 1141 Northview Drive Hillsboro, OH 45133 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed. Event ID: Facility ID: 365621 If continuation sheet Page 3 of 5 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 365621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillsboro Post Acute 1141 Northview Drive Hillsboro, OH 45133 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 medical record reviews, observations, staff interview, and review of facility policy, the facility failed to ensure medications were administered per physician's order resulting in significant medication errors. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Residents Affected - Few Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order for Resident #60 dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365621 If continuation sheet Page 4 of 5 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 365621 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillsboro Post Acute 1141 Northview Drive Hillsboro, OH 45133 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed. Event ID: Facility ID: 365621 If continuation sheet Page 5 of 5