Inspection·November 19, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 09/17/25 at 2:31 P.M., Registered Nurse (RN) #5 stated the pharmacy notified the facility if a medication was missing, when an order required clarification, or a new prescription was needed. RN #5 stated the facility communicated the needs as soon as possible or had pharmacy contact the physician for a prescription. RN #5 further stated it was critical for medications to be delivered timely, particularly when they were not available in the Pyxis. On 09/17/25 at 3:15 P.M., Unit Manager (UM) #3 stated that upon admission, medication orders were sent to the pharmacy, and pharmacy usually delivered the medications the same night. UM #3 stated that if the medication was not in the Pyxis, the nurse must call the pharmacy, and delivery typically occurred within two hours. He stated for Resident #149, the prescribed hypnotic was not available, and the nurse documented the pharmacy was notified. During an interview on 09/17/25 at 3:57 P.M., the Director of Nursing (DON) stated the best practice was to have signed prescriptions available on admission so staff could fax them to the pharmacy and have medications delivered that evening. The DON stated that she was not aware that Resident #149's medication had not been available. The DON stated the facility contacted an on-call nurse practitioner (NP) who called the pharmacy and gave an order for three zolpidem; however, neither staff nor pharmacy called to get another prescription. She stated it was not the facility's standard not to administer medications. The DON stated that she expected staff to call the physician and get a prescription or reach out to her to assist so they could give the resident their medication.During a telephone interview on 09/19/25 at 10:06 A.M., Pharmacist #25 stated that when prescriptions were needed, the pharmacy contacted the provider. Per Pharmacist #25, on 05/25/25, they contacted the physician and received an electronic prescription from the on-call provider for a three-day supply. Pharmacist #25 further stated she did not see evidence of follow-up with the provider until a fascimilie (fax) was sent on 05/27/25. Pharmacist #25 stated they received a valid prescription on 06/02/25 and 10 pills were delivered to the facility. On 09/18/25 at 8:13 A.M., the Administrator stated that regarding Resident #149's medication, they expected the pharmacy to either send the medication or notify the facility if assistance was needed to obtain a prescription.Review of a facility policy titled, Ordering of Drugs (i.e. [id est, that is] Receiving Drug Orders from the Pharmacy, dated 01/2023, indicated, the purpose of exercising control in the ordering of drugs is to assure that the pharmacist dispenses and labels medications properly, assure correct financial responsibility and prompt delivery of drugs. Any shortage or irregularity with the order is documented and made known to the pharmacist on call by telephone.This deficiency represents non-compliance investigated under Complaint Number OH00166335 (1394611). Event ID: Facility ID: 366301 If continuation sheet Page 2 of 6 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 366301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication errors. This resulted in Immediate Jeopardy and serious life-threatening harm to Resident #148, when on [DATE], during admission from another long-term care facility, the facility failed to identify that pages of admission orders were missing from Resident #148's facsimiled (faxed) documents from the referring facility. Subsequently, the facility failed to accurately reconcile Resident #148's medication list and failed to identify an order for apixaban (an anticoagulant medication used to prevent blood clots), which resulted in the resident not receiving the medication. On [DATE], Resident #148 became short of breath and was transferred to a hospital where it was determined Resident #148 had a pulmonary embolism (blood clot in the lungs) and later expired. This affected one (Resident #148) of six residents reviewed for unnecessary medications. The census was 126. On [DATE] at 9:00 A.M., the Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON) #100, Corporate Nurse Educator (CNE) #200, and Regional Nurse #350 were notified Immediate Jeopardy began on [DATE] when, upon admission to the facility, admission orders for administration of apixaban were missing from Resident #148's transfer documents from a previous facility. Resident #148 did not receive the medication throughout the stay in the facility, and on [DATE] Resident #148 began to experience shortness of breath and increased heart rate prompting an evaluation in the hospital. While in the hospital, Resident #148 was diagnoses with a pulmonary embolism and subsequently died as a result. The Immediate Jeopardy was removed and corrected on [DATE] when the facility implemented the following corrective action: Resident #148 no longer resided in the facility. Resident #148's medical record was reviewed by the DON on [DATE]. This included but was not limited to a review of Resident #148's medication list from admission and the admission orders transcribed into electronic medical record (EMR). On [DATE], CNE #200 conducted a review of Resident #148's medical record including but not limited to physician orders, care plans, and administration records. On [DATE], Regional Minimum Data Set (MDS) Nurses #220, #230, #235, and #240 completed an audit of all residents who were admitted to the facility in the last 60 days to ensure admission orders were transcribed correctly into the resident's medical record. Any concerns noted were reviewed with the Nurse Practitioner (NP) #360 and orders updated as needed by licensed nurses by [DATE]. On [DATE], Regional MDS Nurses #220, #230, #235, and #240 verified that all pages of admission orders from transferring facilities were received/present. On [DATE], the DON or designee completed an audit of current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness. On [DATE], the NP #360 reviewed current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness On [DATE], Nurse Educator #280 completed a medication administration observation. No concerns were noted. On [DATE], Registered Nurse (RN) #15 and RN #16 were immediately provided education by the DON. This education included but was not limited to ensuring admitting orders are received and transcribed into the medical record, that all pages of the orders are received, and hard copy of the orders are received upon resident's arrival to facility. By [DATE], licensed nurses were provided with an additional in-service education by the DON and ADON #100. This education included but was not limited to ensuring admission medication orders are reviewed and transcribed into resident medical records, that all pages of the orders are received and that a hard copy of orders is received upon resident's arrival to the facility. A performance improvement (PI) audit worksheet was being completed to verify residents' admitting orders are transcribed completely Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366301 If continuation sheet Page 3 of 6 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 366301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069 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 - Immediate jeopardy to resident health or safety Residents Affected - Few (including all pages are verified) into the medical record. The PI was being completed by the DON or designee for any residents admitting to the facility for the previous day, completing the audit daily for seven (7) days, then three (3) times per week for four (4) weeks, then weekly for 4 weeks, and then monthly. The results of this worksheet will be reviewed by the Quality Assurance and Performance Improvement (QAPI) team. Quality Assurance meetings were held on [DATE] and [DATE] with the Administrator, Medical Director, the DON, CNE #200, Regional Nurse #350, and Consultant Pharmacist #400. On [DATE] through [DATE], five (Residents #6, #9, #11, #58, and #80) additional medical records were reviewed with no concerns for significant medication errors identified. Findings include:Review of the medical record revealed the facility admitted Resident #148 on [DATE] from another nursing home. Resident #148 had a medical history that included diagnoses of atrial fibrillation, hypertension, atherosclerotic heart disease of native coronary artery, and presence of a cardiac pacemaker. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #148 had intact cognition. Resident #148 was admitted from a skilled nursing facility. and had an active diagnosis of atrial fibrillation. The assessment documented Resident #148 did not receive anticoagulant medication during the assessment's look-back period. Review of Resident #148's care plan report included a focus area, initiated on [DATE], that indicated the resident had altered cardiopulmonary status related to pulmonary hypertension, heart failure, and shortness of breath or trouble breathing when lying flat. Interventions directed staff to administer medications as ordered (initiated [DATE]). The care plan report revealed a diagnosis of atrial fibrillation was listed in the Diagnosis section of the care plan; however, anticoagulant therapy was not addressed on Resident #148's care plan. Review of a facility document titled, Medication Error Report Form, dated [DATE], revealed there was a medication error for Resident #148 on [DATE]. Resident #148's apixaban 2.5 milligrams (mg) twice daily was documented as, missed on admission, missing pages of paperwork not sent over on admission. Review of the transferring skilled nursing facility's history and physical, dated [DATE], indicated Resident #148 had unspecified atrial fibrillation, and their heart rate was controlled at the present time with apixaban. Review of Resident #148's document titled, Transfer/Discharge Report, from the transferring skilled nursing facility, with a fax date stamp of [DATE] at 5:42 P.M., indicated the facility received page one (1) of 4 and 3 of 4 of the discharge documentation; and page two (2) of 4 and 4 of 4, which included current medications, were missing from the fax. Further review revealed the fax included Resident #148's Medication Review Report from the transferring facility, which revealed pages 2 of 7, 4 of 7, and six (6) of 7 were missing. Subsequently, there was no order for apixaban for Resident #148 on the faxed Transfer/Discharge Report or the Medication Review Report from the transferring facility. An attempt to obtain the original transfer paperwork from the transferring facility on [DATE] at 10:35 P.M. revealed the facility staff only had access to the information with missing pages that was faxed to the facility on [DATE]. Review of Resident #148's facility document titled, Order Recap (Recapitulation) Report, for [DATE] through [DATE] revealed RN #16 and a Licensed Practical Nurse (LPN) signed the document on [DATE] and RN #15 signed the document on [DATE]. There was no evidence the nurses identified that there were missing pages from Resident #148's Transfer/Discharge Report or Medication Review Report and an order for the anticoagulant (apixaban 2.5 mg twice daily) was not included in the resident's Order Recap Report at the facility. Review of Resident #148's progress notes dated [DATE] at 11:40 A.M. revealed admission medications were verified with NP #360. Review of Resident #148's progress notes dated [DATE] at 12:14 P.M. revealed the NP verified admission medications. Review of Resident #148's progress notes dated [DATE] at 6:49 P.M. revealed staff documented the resident's order recap report was verified with a second nurse. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366301 If continuation sheet Page 4 of 6 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 366301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #148's medication administration record (MAR) for March, April, and [DATE], revealed no documented evidence that the facility administered apixaban to Resident #148 during their stay at the facility. Review of Resident #148's progress notes dated [DATE] revealed NP #360 documented that they saw the resident for reports of shortness of breath and tachycardia (increased heart rate. Resident #148 stated, I just do not know why I feel so poorly. The notes revealed the resident's heart rate fluctuated between 98 to 120 beats per minute (bpm), and the resident's oxygen saturation on room air was 85 percent. Resident #148's oxygen saturation improved to 92 percent on two liters of supplemental oxygen. According to the notes, Resident #148's family member reached out to the resident's cardiologist who suggested the resident go to the emergency room (ER) for an evaluation. The notes revealed the resident's family member requested the resident be sent to the ER. Review of Resident #148's progress notes dated [DATE] at 6:46 P.M. revealed that while the resident was in therapy, the resident had an episode of decreased oxygen and an elevated pulse and blood pressure. The notes revealed NP #360 was notified and saw the resident. The resident had a weird feeling in their chest and was pale. The notes revealed the resident was transferred to the hospital and was admitted with a pulmonary embolism. Review of Resident #148's hospital documentation dated [DATE] at 2:18 P.M. revealed the resident presented with hypoxia (low levels of oxygen in the blood) and hypotension (low blood pressure) while receiving therapy at the skilled nursing facility. On arrival to the emergency department (ED), the resident became increasingly unresponsive and hypoxic to the 70s. The notes revealed that per the resident's family member, the resident was supposed to be on Eliquis (apixaban), but they were unsure whether the facility was providing the medication. The ED note revealed the resident had acute pulmonary emboli, concerns for acute right heart strain and probable pulmonary infarcts in the right upper and lower lung lobes. The note revealed the resident was admitted to the intensive care unit (ICU) for further evaluation and management of a massive pulmonary embolism. Review of Resident #148's ED addendum note dated [DATE] at 4:09 P.M. revealed an ED nurse documented that they contacted LPN #14 at the facility who confirmed that Eliquis was not on the resident's medication list and the facility had not been administering Eliquis. The resident's family member reported that the resident should have been receiving Eliquis and it should not have been stopped. Review of Resident #148's ED notes addendum dated [DATE] at 4:46 P.M. revealed a nurse documented that a hospital case manager contacted the DON at the facility who stated that the resident was transferred to the facility on [DATE] and there was no order for Eliquis. The DON confirmed that Resident #148 had not received Eliquis since she was transferred to the facility on [DATE]. Review of an ED clinical staff pharmacist's progress notes dated [DATE] at 6:55 P.M. revealed the ED pharmacist contacted the pharmacy that filled medications to both the resident's previous facility and current facility. According to the note, it was documented that the pharmacist who worked for the facility pharmacy, Pharmacist #26, that while Resident #148 was at the previous facility from [DATE] to [DATE], Eliquis 2.5 mg for twice daily administration was dispensed. The note revealed that Pharmacist #26 reported that upon transferring to the facility on [DATE], no order was placed for Eliquis 2.5 mg. The notes revealed that Pharmacist #26 indicated that once the skilled nursing facility entered orders into the Point Click Care (PCC) system (the electronic medical record system), the pharmacy filled the orders. Pharmacist #26 confirmed that no order for Eliquis 2.5 mg for twice daily administration had been entered during Resident #148's admission to the facility. Review of a hospital critical care consultation note dated [DATE] at 5:27 P.M. revealed the physician discussed treatment options with Resident #148's family for pulmonary embolism. After discussing the pros and cons and conversing with the resident and other family members on the telephone, the resident/family decided not to pursue the discussed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366301 If continuation sheet Page 5 of 6 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 366301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritagespring Healthcare Center of West Chester 7235 Heritagespring Drive West Chester, OH 45069 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 - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treatment options and opted for no cardiopulmonary resuscitation (CPR), no intubation, and conservative management. During an interview on [DATE] at 11:33 A.M., the Lead Administrator stated the facility was notified that Resident #148 expired. During an interview on [DATE] at 12:43 P.M., RN #16 stated she was the nurse who made the mistake with Resident #148's medication orders on admission to the facility. She stated for resident admissions they reviewed orders uploaded into PCC. However, RN #16 stated that there was an old medication list uploaded for Resident #148 and since the resident was going to be admitted soon, she called the transferring facility and asked them to fax a medication list. She stated she entered the medication orders from the fax but did not notice that pages were missing. When the resident arrived at the facility, the resident's family brought a packet that contained a copy of the same orders that had been faxed. She stated that she documented that the orders were verified with NP #360. RN #16 also stated that within 24 hours a unit manager double-checked the order. During an interview on [DATE] at 9:39 A.M., NP #360 stated that upon admission, medications were reviewed and verified within 24 hours. NP #360 stated she reviewed Resident #148's medication orders and conducted a chart review but did not notice the missing fax. Resident #148's diagnosis of atrial fibrillation would not have triggered her to think the resident should be on Eliquis or any kind of anticoagulant due to the resident's age and other co-morbidities. NP #360 stated she recalled that after the resident was sent to the hospital, they discovered the resident was not receiving a blood thinner. Resident #148 had multiple co-morbidities that contributed to the development of pulmonary emboli on [DATE], and not receiving Eliquis did not help but it was hard to say definitively that it caused the resident's death. During an interview on [DATE] at 11:13 A.M., the ADON stated the admission nurses were responsible for transcribing orders, ensuring all pages and orders were received, and verifying orders with Medical Director (MD) #550. There were transcription errors regarding Resident #148 but he could not provide additional details. During an interview on [DATE] at 1:03 P.M., the DON stated the facility did not receive the complete admitting orders for Resident #148, and there was a transcription error because there were missing pages in the fax. Her expectation was that nurses verify all pages were received. During an interview on [DATE] at 1:57 P.M., MD #550 stated he was familiar with Resident #148 and the incident. MD #550 confirmed the resident did not receive Eliquis while at the facility. He stated that he could not say with 100 percent certainty that not getting Eliquis caused the resident's pulmonary embolism. During an interview on [DATE] at 11:29 A.M., the Administrator stated the hospital notified the facility of the medication error. They found that the even pages of the fax were missing. The Administrator stated that two nurses reviewed Resident #148's orders as required per protocol and the supervisor reviewed the resident's medical record the next day and no one caught the error. During a follow-up interview on [DATE] at 1:18 P.M., the Administrator stated that Resident #148 had a missing medication order. The Administrator stated he expected staff to review orders, ensuring all pages were received at the time of admission. Review of a facility policy titled, Practitioner Order Transcribing/Posting, revised 03/2025, indicated for Admitting Orders staff should review hospital transfer forms/paperwork and enter admit medication/ancillary orders in the EMR. Medication orders include medication name, dose, route of administration, and frequency. Staff should also verify the admission orders with the attending physician/NP/physician assistant and print an order recapitulation report after orders are verified and place copy in chart. Review of a facility policy titled, Administration Oral Medications, revised 11/2024, revealed the facility will ensure patients are given medication per the physician orders. If there are any issues with physician orders, the nurse will contact the physician for clarification. This deficiency represents non-compliance investigated under Complaint Number OH00165685 (1394609). Event ID: Facility ID: 366301 If continuation sheet Page 6 of 6