Inspection·January 8, 2024

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/08/24 at 10:05 A.M. with Resident #81 stated he did not receive a shower on Thursday, 01/04/24. Interview on 01/08/24 at 11:28 A.M. with Director of Nursing (DON) and Regional Nurse #09 verified Resident #81 only received one shower on 12/25/23. The DON and Regional Nurse #09 stated that Resident #81's care plan stated that he preferred his wife to do his baths. The DON and Regional Nurse #09 verified no documentation that showers were given/provided to Resident #81. Interview on 01/08/24 at 12:43 P.M. with Resident #81 denied telling facility he wanted his wife to bathe him. Resident #81 stated he didn't know she was allowed. This deficiency represent non-compliance investigated under Complaint Number OH00149641. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 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 366418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dublin Post Acute 4075 West Dublin-Granville Road Dublin, OH 43017 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital documentation review, staff and resident representative interviews, review of employee personnel files, review of disciplinary action documentation, review of an investigation, and review of facility initiated corrective action, the facility failed to ensure appropriate care was provided to prevent a resident fall. This resulted in actual harm when Resident #98 was transferred by a mechanical (Hoyer) lift incorrectly, and subsequently fell, causing a fracture to inferior pubic ramus and S3 fracture (sacral) which required hospitalization. Additionally, the facility failed to thoroughly investigate an incident when Resident #98 fell from the Hoyer lift. This affected one (#98) of three residents reviewed for falls. The facility census was 96. Findings include: Review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to heart failure, type two diabetes, hypertension, acute kidney failure, and acute respiratory failure with hypoxia. The resident was in the facility for only one day. Review of the baseline care plan dated 12/22/23 revealed fall risk characterized by new environment, generalized weakness, and possible side effects of medications. Interventions included observe for adverse effects of medications, including dizziness, drowsiness, and sedation. If symptoms observed, assist with activities of daily living (ADL's), and notify doctor. Therapy to screen and treat as necessary per doctor's order. Review of the nurse's note dated 12/22/23 at 11:15 A.M. revealed Resident #98 was reported unresponsive at around 10:30 A.M., code blue was called. While staff were assessing the resident and placing the automated external defibrillator (AED) pads, the resident noted to become responsive and able to answer questions. AED use discontinued and was not needed for the event. Resident #98 endorsed generalized pain. Skin tear to right upper arm noted. Pressure dressing applied. Family at bedside and witness to resident care. Resident #98 assessed by Nurse Practitioner (NP). Resident #98 was taken to the hospital per family request after Emergency Medical Technicians (EMT's) noted to place resident in wheelchair from the floor after assessing resident. Per staff present in resident room providing care, and family member, the resident was in the middle of being transferred from the bed to wheelchair with Hoyer lift, with two staff members operating, for dialysis appointment when the resident fell out of mechanical lift sheet to the floor while being lowered into the wheelchair. Review of the incident investigation dated 12/22/23 revealed two (#537 and #522) State Tested Nursing Assistants (STNA's) were transferring Resident #98 with the Hoyer lift from the bed to the wheelchair when the resident fell out of the mechanical lift sheet onto floor. Resident #98 was transported to the hospital with skin tear to right upper arm and hitting head. Review of the hospital document dated 12/22/23 revealed Resident #98 had a fall from Hoyer lift with Computed Tomography (CT) of musculoskeletal pelvis with age indeterminate inferior pubic ramus fracture and sacral fracture, CT anterior posterior with pubic ramus fracture and ascites/anasarca but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 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 366418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dublin Post Acute 4075 West Dublin-Granville Road Dublin, OH 43017 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 no acute intra-abdominal or intra-pelvic pathology. No acute surgical intervention planned. Tylenol and Tramadol as needed for pain. Level of Harm - Actual harm Residents Affected - Few Interview on 01/02/24 at 2:35 P.M. with STNA #537 stated that she was the aide caring for Resident #98 on 12/22/23. STNA #537 stated she went into Resident #98's room on 12/22/23 at 10:30 A.M. with another STNA to transfer Resident #98 with a Hoyer lift. One of the straps at the feet came undone when they tried to sit the resident up in an upright position to get him into the wheelchair. STNA #537 stated Resident #98 slid out the feet side of the lift pad onto bottom. STNA #537 stated Resident #98 was almost in wheelchair. STNA #537 denied tying the sling to the lift. Interview on 01/03/24 at 2:13 P.M. with the Administrator revealed both (#537 and #522) STNA's refused to give written statements regarding the incident where Resident #98 fell from the Hoyer lift on 12/22/23. Both stated they gave verbal statements to the Assistant Director of Nursing (ADON) and both STNA's still work at the facility. The Administrator stated he was initially told that the Hoyer sling came unattached, and Resident #98 was lowered to the floor. The Administrator stated Resident #98 was a dialysis patient, and the dialysis center sends their own Hoyer slings and the STNA's thought that sling would work in their lifts. The Administrator stated he was told the STNA's attempted to tie the corner of the sling to the lift. The Administrator was told the loop by the resident's right shoulder came undone and he fell out of the sling onto his bottom and fell back and hit his head on a piece of furniture. The Administrator stated STNA's #537 and #522 were disciplined, and all Hoyer lifts were put out of commission with the pads. A telephone interview on 01/03/24 at 3:14 P.M. with Licensed Practical Nurse (LPN) #625 stated that from what he understood STNA's #537 and #522 were attempting to transfer Resident #98 from the bed to the wheelchair when in the middle of the transfer Resident #98 ended up falling out of the lift sling. LPN #625 stated Resident #98 went unresponsive, so a code blue was called. By the time he arrived at the room with the NP, Resident #98 began to respond. LPN #625 stated Resident #98 was assessed by the NP and then the squad came. EMT's assisted and lifted the resident to the wheelchair. LPN #625 stated the sling was tied to the Hoyer lift. LPN #625 stated he found three of the straps that were not attached to the lift when he removed it to give to the EMT's. LPN #625 stated STNA's #537 and #522 used the dialysis' slings, which have loops instead of hooks. Interview on 01/03/24 at 3:22 P.M. with STNA #522 revealed they used the wrong Hoyer pad to transfer Resident #98 on 12/22/23 and the resident fell from the Hoyer lift and hit his bottom. STNA #522 told the Director of Nursing (DON) they needed to replace Hoyer slings in the facility. A telephone interview on 01/04/24 at 9:07 A.M. with Family Member (FM) #700 stated Resident #98 was dropped from a Hoyer lift and sustained a tailbone fracture. The resident had a few hairline cracks in the pubic area, but they were not sure if those happened during the fall. The resident is expected to recover from the fractures. FM #700 was present in the room when the incident occurred. FM #700 stated STNA's #537 and #522 did not cross the leg straps when hooking the resident up to the lift. FM #700 further explained the Hoyer pad had rectangular plastic tabs that attached to the bolt like things on the lift. When STNA's #537 and #522 lifted the resident, his legs came apart causing the sling to come unattached, and he fell out of sling onto the floor. The resident's legs came out first and he fell straight down onto his bottom and then fell back and hit his head. Interview on 01/09/23 at 9:35 A.M. with the DON verified the Hoyer sling went to the hospital with the resident and the facility did not obtain the Hoyer sling from the hospital. The DON further verified the facility was unsure which sling the STNA's used for the transfer, whether it was the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 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 366418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dublin Post Acute 4075 West Dublin-Granville Road Dublin, OH 43017 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 dialysis sling or a facility sling. Level of Harm - Actual harm Review of the disciplinary documentation dated 12/22/23 revealed STNA #522 and STNA #537 received a written warning regarding failure to use medical equipment correctly resulting in the injury of a patient. Residents Affected - Few Review of facility policy titled, Mechanical Lift reviewed 06/08/22 revealed partially lift the resident and check that the resident is safely positioned in the lift and the loops are secure before moving the resident's legs off the bed. This deficiency represents non-compliance investigated under Complaint Numbers OH00149713, OH00149513 and OH00148805. The deficient practice was corrected on 12/24/23 when the facility implemented the following corrective actions: 12/22/23 Resident assessed by NP and nursing staff. EMT's assessed resident and resident transported to the hospital at 11:09 A.M. 12/22/23 at 11:10 A.M. Hoyer in use with resident was pulled from service due to Hoyer pad going to the hospital with resident and unable to assess the pad. 12/22/23 at 11:20 A.M. Both STNAs involved were immediately educated and disciplined. 12/22/23 Root Cause Analysis completed identifying the root cause to be utilizing the incorrect sling for the transfer. QAPI Plan initiated including nursing education and all mechanical lifts were to be taken out of service with rental lifts to be brought in for use. 12/22/23 Initial audit completed identifying the residents needing to use a mechanical lift and verified their mechanical lift pads were appropriate for use. 12/22/23 at 11:20 A.M. Mechanical lift education started with all nursing staff following the incident and continued for two days, ending on 12/24/23. All staff were educated before working the floor. 12/22/23 at 12:30 P.M. New rental Hoyer lifts ordered. 12/23/23 rental Hoyer lifts in use until inspection of facility Hoyer lifts are completed and pads are inspected and compatible with Hoyer lifts. Observation on 01/03/24 with two STNA's performing a mechanical (Hoyer) lift transfer revealed no concerns. Interviews on 01/04/24 from 11:33 A.M. to 11:56 A.M. with STNAs #504, #503, #502, and #509, Registered Nurse (RN #619) and LPN #634 verified they had received training on the use of the Hoyer lift machine and Hoyer lift transfers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 5 of 5