Health inspection·May 3, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on review of medical record, staff interviews and review of policy, the facility failed to ensure a resident representative was notified of a significant weight loss for a resident. This affected one (#19) of one resident reviewed for notification of change. The census was 49. Findings include: Review of Resident #19's medical record revealed she admitted to the facility 09/15/20. Diagnoses included fracture of right humerus and dementia. A dietary note dated 03/24/21 revealed Resident #19 lost 16 pounds since February 2021. Her supplement was increased and the physician was notified. There was no evidence her resident representative being notified of her weight loss. Interview on 04/27/21 at 12:42 P.M., Dietician #307 stated nursing staff were responsible for notifying resident representatives of dietary/nutritional changes. Interview on 04/27/21 at 12:43 P.M., Director of Nursing stated Dietician #307 was responsible for notifying resident representatives of dietary and nutritional changes. He confirmed Resident #19's resident representative was not notified of her weight loss identified 03/24/21. Review of a facility policy titled, Change of Condition, dated 10/18/01, revealed the unit manager or charge nurse was responsible for notifying the resident representative of any change in condition, including weight loss. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 2 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, review of facility policy and facility checklist, the facility failed to ensure a resident was free from the use of a physical restraining device utilized by staff and preventing the resident freedom of mobility. This affected one (#20) of one resident reviewed for physical restraints. The facility identified no residents who used physical restraints. The census was 49. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed he admitted to the facility 10/15/20. Diagnoses included encephalopathy, muscle weakness, insomnia, Dementia with Lewy Bodies, and major depressive disorder with psychotic symptoms. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE], revealed he had a severe cognitive impairment. He required a one person extensive assist with bed mobility and a two person physical assist with transfers. A bed alarm was used daily. There was no assessment of a restraint being used. Review of Resident #20's care plan initiated on 10/16/20 and revised on 11/03/20, revealed Resident #20's wife stated he had a history of visual hallucinations and would lay self on floor and frequently attempted to stand without assistance. Interventions did not include use of a wedge pillow. Review of Resident #20's insomnia care plan last revised 11/03/20, did not include the use of a wedge pillow. His activity of daily living care plan dated 10/20/20 revealed he required a two person assist with repositioning and bed mobility. Interventions did not include the use of a wedge pillow below his mattress. Review of Resident #20's skin integrity care plan dated 10/16/20 revealed an intervention of a pressure reducing mattress. The care plan did not include the use of a wedge pillow below the mattress. Further review of Resident #20's care plan created 10/16/20 and last revised 10/30/20 revealed he was at risk of falls secondary to Lewy Body Dementia and restless legs. He was observed crawling out of bed onto the floor mat. Interventions included non skid socks as tolerated (11/08/20); rest in recliner before lunch (12/18/20); encourage activities after breakfast (12/20/20); offer to lay down after dinner (12/21/20); medication review (12/26/20); stirrup over non-skid socks as tolerate (03/08/21) and sounding alarm on bed as tolerated (02/04/21). Interventions dated 10/16/20 also included floor mat next to bed at all times, geriatric hip protectors on as tolerated, and low bed. Observations on 04/28/21 at 7:30 A.M. and 8:26 A.M., revealed Resident #20 lying flat on his back in his bed. His bed was in the lowest position and Resident #20 faced the door to the hallway. The left side of Resident #20's bed was against the wall. A standard wedge pillow (measuring 32 inches by 20 inches, by 12 inches at a 20 degree angle) was placed under the center of Resident #20's mattress. Either side of the wedge pillow was raised 12 inches from the base of the bed at a twenty degree angle. Resident #20 was flat on his back, his right arm against the wall and his left arm secured him to the position due to the angle the mattress laid due to the wedge pillow beneath it. Observation and interview on 04/28/21 at 8:32 A.M., with Director of Nursing (DON) confirmed the above description of the position of Resident #20 in his bed. DON stated it was something the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 3 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few night-shift staff had done to help reposition Resident #20 to prevent skin breakdown. DON confirmed Resident #20 did not have any current skin conditions and the wedge limited his freedom of movement. Further interview on 04/28/21 at 10:43 A.M., with DON confirmed Resident #20 was on hospice but hospice staff did not place the wedge cushion. DON stated he interviewed night shift staff from the previous night and they placed the wedge to assist Resident #20 with positioning as he could not tolerate laying flat on his back. A restraint-enabler decision tree was completed. Staff were re-educated to utilize pillows for positioning above the mattress as opposed to a wedge pillow below the mattress. DON confirmed Resident #20 was observed lying on his back during the mutual observation, not positioned on his side as night shift stated. DON confirmed Resident #20 required two person physical extensive assist to get out of bed and one person extensive physical assist with bed mobility. DON stated during the Restraint-Enabler Decision Tree assessment, revealed the wedge pillow use did not prevent Resident #20 from exiting the bed. DON stated the intervention of the wedge pillow had never been discussed between himself and night shift staff. He stated there was no documentation of when the intervention was implemented or who was notified the intervention was implemented. DON stated Resident #20 was unable to remove the wedge pillow from underneath his mattress. DON stated staff were never educated to use a wedge pillow under the mattress for repositioning and it was not facility policy. He stated interventions were typically developed by nursing management, not State Tested Nurse Aides. He stated the facility night shift staff were educated to not use the wedge pillow under resident mattresses. Review of a facility policy titled, Restraint Use, dated 06/20/15, revealed a physical restraints were defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual could not remove easily which restricted freedom of movement or normal access to one's body. Review of an undated checklist titled, Turing and Repositioning while in Bed, did not include placing a wedge pillow under the mattress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 4 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of Self-Reported Incident Report (SRI) and review of policy, the facility failed to obtain the required documentation to discharge a resident form the facility. This affected one (#149) of two residents reviewed for discharge from the facility. The facility census was 49. Findings include: Review of Resident #149's closed medical record revealed an admission date of 11/12/20 and readmitted on [DATE]. The resident was discharged on 04/16/21. The resident's diagnoses included: chronic obstructive pulmonary disease, paranoid schizophrenia, Alzheimer's disease, anxiety, depression, and epilepsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Resident #149 was mobile though out the facility and required supervision for activities of daily living. Review of the Self-Reported Incident Report Form (SRI) tracking #205019 revealed on 04/16/21, Resident #149 and another resident were involved in an altercation. The other resident was sitting in the dining room in a chair Resident #149 routinely occupied. Resident #149 saw the other resident in his chair and pushed the resident out of the chair onto the floor. The residents were immediately separated and monitored by individual staff providing 1:1 supervision. Both residents were calm. Their physicians were notified, and orders were received for precautionary measures to send both residents to the hospital for further evaluation. The other resident was sent to the hospital in an ambulance. Resident #149 waited quietly with the maintenance man until a local police officer arrived to escort Resident #149 to the hospital. The SRI was investigated by facility Administrator. The Administrator concluded based on the investigation the allegation of abuse or suspicion of abuse was unsubstantiated. The evidence did not indicate abuse occurred. Both residents had cognitive impairment and were easily redirected following the incident. Review of the physician's order dated 04/16/21 revealed an order to send the resident to emergency room Stat for further evaluation. There were no physician orders to indicate Resident #149 could not return to the facility or to support an Emergency Discharge from the facility. Interview on 04/29/21 at 9:00 A.M., with the Director of Nursing verified there were no orders from the physician to discharge Resident #149 from the facility. There was no documentation from the physician regarding the reason for the transfer or discharge. Review of the policy titled Discharge Process for Planned Discharges dated 04/30/18, revealed the facility will obtain a physician's order for the discharge. This deficiency substantiates Complaint Number OH00121908. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 5 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, review of Self-Reported Incident report, and review of policy, the facility failed to allow a resident to return to the facility after seeking treatment at the emergency room. This affected one (#149) of two residents reviewed for discharges. The facility census was 49. Findings include: Review of Resident #149's closed medical record revealed an admission date of 11/12/20 and readmitted on [DATE]. The resident was discharged on 04/16/21. The resident's diagnoses included: chronic obstructive pulmonary disease, paranoid schizophrenia, Alzheimer's disease, anxiety, depression, and epilepsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment. Resident #149 was mobile though out the facility and required supervision for activities of daily living. Review of the Self-Reported Incident Report Form (SRI) tracking #205019 revealed on 04/16/21, Resident #149 and another resident were involved in an altercation. The other resident was sitting in the dining room in a chair Resident #149 routinely occupied. Resident #149 saw the other resident in his chair and pushed the resident out of the chair onto the floor. The residents were immediately separated and monitored by individual staff providing 1:1 supervision. Both residents were calm. Their physicians were notified, and orders were received for precautionary measures to send both residents to the hospital for further evaluation. The other resident was sent to the hospital in an ambulance. Resident #149 waited quietly with the maintenance man until a local police officer arrived to escort Resident #149 to the hospital. The SRI was investigated by facility Administrator. The Administrator concluded based on the investigation the allegation of abuse or suspicion of abuse was unsubstantiated. The evidence did not indicate abuse occurred. Both residents had cognitive impairment and were easily redirected following the incident. Review of the physician's order dated 04/16/21 revealed an order to send the resident to emergency room Stat for further evaluation. There were no physician orders to indicate Resident #149 could not return to the facility or to support an Emergency Discharge from the facility. Review of the transfer notice dated 04/16/21 revealed the reason for the transfer was due to the safety of individuals in the home. Review of the Emergency Discharge Notice form, dated 04/16/21, indicated the resident was pinked slipped to the hospital because, the safety of individuals in the home would otherwise be endangered. A certified copy of the notice was sent to the resident's representative on 04/19/21 with no return of receipt record. Review of the Social Service Designee's Progress Notes, dated 04/16/21, revealed she informed a hospital nurse of the emergency discharge notice and confirmed the resident could not return to the facility. There was no other documentation in the residents chart about the discharge to the hospital. Interview on 04/28/21 at 11:30 A.M., with the Regional Director of Nursing (RDON) #312 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 6 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #149 was pink slipped to the hospital. A transfer notice and an Emergency Discharge Notice were provided to the Emergency Medical Technician indicating Resident #149 was not allowed to return to the facility. The Ohio-State Long Term Care Ombudsman was notified, and a copy of the notice was sent to the Ohio Department of Health. The RDON #312 stated we did everything we could for this resident there was nothing else we could do to meet his needs. He denied knowing where Resident #149 went after he was discharged from the hospital. He confirmed there were no plans and no alternate placements discussed prior to sending Resident #149 to the hospital on [DATE]. Interview on 04/28/21 at 3:15 P.M., with the Administrator revealed they could not take Resident #149 back after being pink slipped because, enough was enough. The Administrator asserted they could not help Resident #149 any longer even though they pink slipped him in the past and got his medications stable. She stated, the facility is for behaviors not a psychiatric facility. She confirmed there were no efforts in the past to discharge Resident #149 to an appropriate facility when he displayed aggressive behaviors, refused medications, or voiced that he wanted to die. The Administrator could not provide any proof that Resident #149 family member received the certified letter notifying them of the Resident #149 Emergency Discharge. Interview on 04/29/21 at 9:00 A.M., with the Director of Nursing verified there were no orders from the physician to discharge Resident #149 from the facility. There was no documentation from the physician regarding the reason for the transfer or discharge. Review of the policy titled Discharge Process for Planned Discharges dated 04/30/18, revealed the facility will obtain a physician's order for the discharge. This deficiency substantiates Complaint Number OH00121908. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 7 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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. Review of resident medical records and staff interviews, revealed the facility failed to refer a resident with new mental disorder for a new pre-admission screening and resident review (PASRR). This affected three (#15, #25, and #12) of five residents reviewed for appropriate PASRR completion. The census was 49. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 09/09/20, with a diagnosis including a mood disorder. Review of Resident #15's pre-admission screening and resident review (PASRR) dated 08/29/20 revealed the screening did not have indicators of serious mental illness or developmental disability. Review of Resident #15's diagnoses list revealed she received a new diagnoses on 09/09/20 of bipolar disorder with psychotic features, unspecified psychosis, and anxiety. Further review of her medical record revealed no additional PASRR was completed after receiving new mental health diagnoses. 2. Review of Resident #25's medical record revealed an admission date of 09/19/20. Diagnoses included bipolar disorder and cystitis. Review of the PASRR dated 09/19/20 included his mood disorder. Further review of Resident #25's medical record revealed on 10/02/20, he was diagnosed with paranoid schizophrenia. There was no evidence a resident review was completed and referred to the appropriate agency. 3. Review of Resident #12's medical record revealed an admission date of 11/05/20. Diagnoses included encephalopathy upon admission. Review of the PASRR dated 03/21/18 revealed she had a mood disorder and was identified as a level one resident. Further review of Resident #12's medical record revealed she received a new diagnosis of schizophrenia 11/05/20. Further review of her medical record revealed no further PASRR was completed Interview on 04/29/21 at 8:45 A.M., with Social Service Director #306 confirmed Resident #15, Resident #25, and Resident #12 received new mental health diagnoses and were not referred to the Ohio Board of Mental Health for evaluation. She stated the facility did not have a PASRR policy. Interview on 05/03/21 at 12:40 P.M., with Director of Nursing (DON) revealed the facility did not have a policy to guide staff on the PASRR process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 8 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 observation, record review, staff interviews and review of policy, the facility failed to implement fall preventions as care planned. This affected one (#37) of four residents reviewed for accidents. The facility identified seven residents at risk for falls. The facility census was 49. Findings include: Review of Resident #37's medical record revealed an admission date of 11/18/20. Diagnoses included cerebral palsy and mild intellectual disability. Review of his Minimum Data Set (MDS) assessment dated [DATE], revealed he had a moderate cognitive impairment and required extensive assistance from staff for activities of daily living. Review of a nursing progress note dated 04/16/21 revealed Resident #37 was found on the floor after he jumped out of bed per resident interview. The progress note revealed a new intervention of fall mat beside his bed. Review of Resident #37's care plan revealed he received a new fall intervention of fall mat next to bed. Observation on 04/28/21 at 8:42 A.M., revealed Resident #37 was sleeping in bed. His bed was in the lowest position and no fall mat was present. Interview on 04/28/21 at 8:51 A.M., with State Tested Nursing Assistant (STNA) #305 revealed she did not know where to find out the fall interventions each resident needed. She did not know the interventions Resident #37 was care planned for or how to find out. Interview and observation on 04/28/21 at 9:00 A.M., with Administrator confirmed Resident #37's fall mat was not in place per his care plan to prevent injury. Review of a facility policy titled, Fall Management, dated 10/17/16, revealed each residents' plan of care would be implemented to prevent a fall or injury related to a fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 9 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure supporting evidence and diagnosis for the continual use of a medication for sexual behaviors. This affected one (#44) of five residents reviewed for unnecessary medications. The facility census was 49. Residents Affected - Few Findings include: Review of the Resident #44's medical record revealed an admission date of 10/29/20, with diagnoses of Huntington's disease, transient ischemic attack, psychosis, and major depressive disorder. Review of a physician order dated 11/11/20 at 10:29 P.M., revealed an order for Resident #44 to take Tagamet (Gastric Acid Secretion Reducers) 30 milligrams two times a day for sexual behaviors. Review of nurses' progress notes dated 11/11/20, revealed Resident #44 was in Resident #250's room attempting to kiss him. The nurse redirected her to her room where she remained for the rest of the evening. Review of the Resident #44's nurses' progress notes from 10/29/20 to 11/11/20 and from 11/12/20 to 04/27/21 revealed no concerns with Resident #44 displaying any type of sexual behavior. Review of the Medication Administration Records from 11/11/20 to 04/27/21 revealed Resident #44 continues to take Tagamet 30 milligrams two times a day for sexual behaviors. Review of the psychiatrist evaluation of Resident #44 dated 11/09/20 revealed no indications Resident #44 has a history of or displaying sexualized behaviors. Interview on 05/02/21 at 11:02 A.M., with the Director of Nursing (DON) confirmed there is no documentation to indicate Resident #44 displayed sexual behaviors since 11/11/20. He confirmed Resident #44 is still on Tagamet 30 milligrams two times a day for sexual behaviors. Review of the policy titled Unnecessary Drugs Policy and Procedures dated 06/27/15, revealed, any drugs when used without adequate monitoring and continued indicators for its use should be reduced or discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 10 of 11 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 366303 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highbanks Care Center 111 Lazelle Road East Columbus, OH 43235 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 0826 Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a speech therapy order was implemented to evaluate a resident who was displaying difficulty chewing. This affected one (#6) of eight residents reviewed for nutrition services. The census was 49. Residents Affected - Few Findings include: Review of the Resident #6's medical record revealed an admission date of 01/27/21, with the diagnoses of encephalopathy, dementia with behavioral disturbances, cerebral infarction, and anxiety disorder. Review of Resident #6's Physician Order Summary Report dated 01/27/21 to 05/03/21 revealed a standing order for Resident #6 to have speech or physical therapy as needed. Review of Resident #6's nurses' progress notes dated 04/06/21 at 1:24 P.M., revealed Resident #6 complained to the nurse of chewing difficulties. The nurse completed a speech therapy referral form for Resident #6 to be evaluated. Resident #6's guardian and physician were notified. Observations on 04/26/21 at 12:30 P.M., revealed Resident #6 did not eat his lunch. Interview with Resident #6 at the time of the observation, stated the meat was too big and tough. He tried to eat it, but it hurt his teeth. Interview on 04/28/21 at 11:10 A.M., with Physical Therapist #320 revealed they did not have a speech therapy referral for Resident #6. He shared Resident #6 has not been evaluated. Review of a facility policy titled, Medical Nutrition Therapy Best Practices for High risk Areas, last revised September 2016, suggested interventions including speech therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366303 If continuation sheet Page 11 of 11