Health inspection·February 8, 2024

F 0550 This deficiency represents non-compliance investigated under Master Complaint Number OH00150624, Complaint Number OH00150384, and Complaint Number OH00150282. 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: 366418 If continuation sheet Page 2 of 15 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 02/08/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to report an incident of potential misappropriation and verbal abuse. This affected two (Resident #46 and #51) of four residents reviewed for abuse. The facility census is 113. Findings include: Review of the medical record for Resident #51 revealed an admission date of 04/13/23 with diagnoses including cerebral infarction due to embolism, human immunodeficiency virus, schizophrenia, bipolar disorder, anxiety disorder, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/31/23, revealed Resident #51 had intact cognition. Review of the progress note, dated 01/11/24, revealed Resident #51 was complaining about her former roommate, (Resident #46) and stated she had taken her green blanket. Resident #51 continued to scream at Resident #46 as caregivers prevented Resident #51 from entering Resident #46's room. Later, Resident #51 called her daughter and she stormed the facility shouting at staff. She later went to Resident #46's room and pulled the blanket off of her bed. She continued shouting at staff, but the staff did not respond. Resident #51 was advised not to interact with Resident #46 and both residents were left safe in their rooms. Review of the medical record for Resident #46 revealed an admission date of 07/27/23 with diagnoses including polyneuropathy, chronic kidney disease stage three, bladder disorder, and polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 had intact cognition. Review of Resident #46's medical record revealed it was absent for any documentation related to the incident involving Resident #51 and Resident #51's daughter which occurred on 01/11/24. Review of the facility self-reported incidents (SRI) revealed the facility had not reported the incident on 01/11/24 involving Resident #46, Resident #51, and Resident #51's daughter. Interview on 01/30/24 at 1:58 P.M. with Licensed Practical Nurse (LPN) #205 revealed she had been working on 01/11/24 when the incident involving Resident #46, Resident #51, and Resident #51's daughter took place. She reported Resident #51 had become upset and stated her ex-roommate took her blanket. They both had the same blanket, and neither was labeled. LPN #205 told Resident #51 she would look into it, but Resident #51 went to another nurse asking to go in Resident #46's room and Resident #51 was told no. Resident #51 called her daughter who came bursting in the facility and went straight to Resident #46's room. LPN #205 stated she was in another resident's room when the incident began, but the aides came to get her. When LPN #205 arrived, the daughter was dragging the blanket out of Resident #46's room and she had thrown things around. Resident #51's daughter was still yelling at that time. LPN #205 told her she could not yell in the facility, but she would not stop. Resident #51's daughter brought the blanket to her mother and left the faciity on the phone with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 3 of 15 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 02/08/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Administrator. LPN #205 stated she checked on Resident #46 who was in her room in a chair when Resident #51's daughter entered her room. LPN #205 comforted Resident #46 who had been shaking when she checked in on her. Resident #46 was not worried about the blanket and stated she would take any blanket as a replacement. LPN #205 reported Resident #51's daughter comes in almost every day and verified Resident #51 and Resident #46's rooms were right next to each other. Residents Affected - Few Interview on 01/31/24 at 12:51 P.M. and 2:10 P.M. with Regional Clinical Manager #201 revealed she was unaware of any incident on 01/11/24 between Resident #46, Resident #51, and Resident #51's daughter. Further interview on 02/01/24 at 10:59 A.M. revealed she found no additional information indicating the incident on 01/11/24 was reported or investigated. Regional Clinical Manager #201 reported she had learned the blanket was a facility given Christmas present that both residents had received. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 10/24/22, revealed all incidents and allegations must be reported immediately to the Administrator or designee. Allegations of abuse or serious bodily injury should be reported to the Ohio Department of Health immediately but no later than two hours after the allegation is made and all other allegations should be reported no later than 24 hours from the time of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 4 of 15 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 02/08/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of facility investigations, review of Self-Reported Incidents, staff interview, resident interview, and facility policy review, the facility failed to thoroughly investigate incidents of potential abuse. This affected four residents (#46, #51, #84, and #101) out of four residents reviewed for abuse. The facility census was 113. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #84 revealed an admission date of 01/04/24 with diagnoses including Chronic Obstructive Pulmonary Disorder, diaphragmatic hernia, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/11/24, revealed Resident #84 had moderately impaired cognition. Review of the Self-Reported Incident (SRI) form for SRI tracking number 242911, revealed the date of discovery was 01/09/24. The form further revealed an allegation of physician and emotional or verbal abuse was made by Resident #84. Resident #84 alleged that while providing care, two State Tested Nursing Assistant's (STNA) hurt her stomach and made her apologize for saying they hurt her. The STNA's were removed from the patient area and were suspended pending an investigation. The facility concluded the allegation was unsubstantiated. Review of the narrative summary for SRI tracking number 242911, revealed Resident #84 reported to the infection preventionist that two STNA's were mean to her and hurt her stomach during care and she was unable to give a description of staff. The Administrator interviewed Resident #84 who was able to give a date and time. Resident #84 reported the two STNA's hurt her when they repositioned her and when she mentioned this during the care, the two STNA's denied touching her stomach and reported she was just tender due to a recent surgery. Resident #84 stated the STNA's then told her she needed to apologize to them for accusing them of hurting her. The Administrator reviewed the staff on-schedule and determined who the STNA's were, and both were suspended. Both STNA's were asked to describe their interactions with Resident #84. Both STNA's indicated they did in fact provide care to Resident #84 and had pleasant interactions with Resident #84. They denied any unusual circumstances or allegations. Both STNA's were re-assigned and removed from patient areas. The social worker interviewed residents and found no concerns. There was a statement indicating additional staff were interviewed and denied knowledge of the incident or any allegation of abuse. Review of the facility investigation documents for SRI tracking number 242911, revealed there was no indication of which additional staff were interviewed or if all of the other staff who worked with Resident #84 that day were identified and interviewed. Review of the SRI form for SRI tracking number 243252, revealed on 01/19/24, the Administrator was made aware by a third party insurance case manager of an allegation of neglect. Resident #84 alleged STNA #421 told her that if she activated her call light again, he would take the call light away from her. STNA #421 was removed from the patient area and suspended pending the outcome of the investigation. The facility concluded the allegation was unsubstantiated. Review of the narrative summary for SRI tracking number 243252, revealed the insurance case manager reported the incident to the Administrator on 01/19/24 and STNA #421 was removed from the schedule and suspended immediately. The Administrator interviewed Resident #84 who repeated the allegation. A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 5 of 15 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 02/08/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm member of the nursing staff completed a head-to-toe assessment, and no remarkable findings were indicated. The investigation included an interview with STNA #421 who denied the allegation. STNA #421's personnel file was reviewed and it was absent of previous infractions and STNA #421 had been educated on abuse. Like residents were interviewed with no concerns noted. It was indicated additional staff were interviewed related to the allegation and denied any knowledge of the allegation or any abuse. Residents Affected - Few Review of the facility investigation documents for SRI tracking number 243252 revealed there were no written statements by STNA #421. Additionally, there was no indication of which additional staff were interviewed or if other staff who worked with Resident #84 that day were identified and interviewed. Interview on 01/30/24 at 2:32 P.M. with Regional Clinical Manager #201 verified the description of the additional staff who were interviewed as well as a witness statement for STNA #421 was not included in the investigation. The interview further verified there was no evidence in the SRI investigations that the additional staff working with Resident #84 on the days of the alleged incidents were interviewed as part of the investigation. 2. Review of the medical record for Resident #51 revealed an admission date of 04/13/23 with diagnoses including cerebral infarction due to embolism, human immunodeficiency virus, schizophrenia, bipolar disorder, anxiety disorder, and diabetes mellitus. Review of the quarterly MDS 3.0 assessment, dated 10/31/23, revealed Resident #51 had intact cognition. Review of the progress note, dated 01/11/24, revealed Resident #51 was complaining about her former roommate (Resident #46) and stated she had taken her green blanket. Resident #51 continued to scream at Resident #46 as caregivers prevented Resident #51 from entering Resident #46's room. Later, Resident #51 called her daughter and she stormed the facility shouting at staff. She later went to Resident #46's room and pulled the blanket off of her bed. She continued shouting at staff, but the staff did not respond. Resident #51 was advised not to interact with Resident #46 and both residents were left safe in their rooms. Review of the medical record for Resident #46 revealed an admission date of 07/27/23 with diagnoses including polyneuropathy, chronic kidney disease stage three, bladder disorder, and polyosteoarthritis. Review of the quarterly MDS 3.0 assessment, dated 11/03/23, revealed Resident #46 had intact cognition. Review of Resident #46's medical record revealed it was absent for any documentation related to the incident involving Resident #51 and Resident #51 which occurred on 01/11/24. Review of the facility self-reported incidents (SRI) revealed the facility had not reported the incident on 01/11/24 involving Resident #46, Resident #51, and Resident #51's daughter. Furthermore, there was no evidence the facility had completed an investigation of the incident involving Resident #46, Resident #51, and Resident #51's daughter. Interview on 01/30/24 at 1:58 P.M. with Licensed Practical Nurse (LPN) #205 revealed she had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 6 of 15 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 02/08/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few working on 01/11/24 when the incident involving Resident #46, Resident #51, and Resident #51's daughter took place. She reported Resident #51 had become upset and stated her ex-roommate took her blanket. They both had the same blanket, and neither was labeled. LPN #205 told Resident #51 she would look into it, but Resident #51 went to another nurse asking to go in Resident #46's room and Resident #51 was told no. Resident #51 called her daughter who came bursting in the facility and went straight to Resident #46's room. LPN #205 stated she was in another resident's room when the incident began, but the aides came to get her. When LPN #205 arrived, the daughter was dragging the blanket out of Resident #46's room and she had thrown things around. Resident #51's daughter was still yelling at that time. LPN #205 told her she could not yell in the facility, but she would not stop. Resident #51's daughter brought the blanket to her mother and left the faciity on the phone with the Administrator. LPN #205 stated she checked on Resident #46 who was in her room in a chair when Resident #51's daughter entered her room. LPN #205 comforted Resident #46 who had been shaking when she checked in on her. Resident #46 was not worried about the blanket and stated she would take any blanket as a replacement. LPN #205 reported Resident #51's daughter comes in almost every day and verified Resident #51 and Resident #46's rooms were right next to each other. Interview on 01/31/24 at 12:51 P.M. and 2:10 P.M. with Regional Clinical Manager (RCM) #201 revealed she was unaware of any incident on 01/11/24 between Resident #46, Resident #51, and Resident #51's daughter. Further interview with RCM #201 on 02/01/24 at 10:59 A.M. revealed she found no additional information indicating the incident on 01/11/24 involving Resident #46, Resident #51, and Resident #51's daughter was reported or investigated. RCM #201 reported she had learned the blanket was a facility given Christmas present that both residents received. 3. Review of the medical record for Resident #101 revealed an admission date of 11/28/20. Medical diagnoses included multiple sclerosis, difficulty in walking, chronic pain syndrome, and muscle weakness. Review of the Quarterly MDS 3.0 assessment, dated 01/13/24, revealed Resident #101 had a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of the progress notes for Resident #101 from 12/01/23 to 02/05/24 revealed no mention of any allegations of abuse of any kind. A progress note dated 01/11/24 at 7:24 P.M. revealed Resident #101 refused to go to the hospital. A social service progress note dated 01/13/24 at 1:36 P.M. revealed Resident #101 was at her baseline mental status and her cognition remained intact. A progress note dated 01/15/24 at 5:33 P.M. revealed the Certified Nurse Practitioner (CNP) placed an order for Resident #101 to be sent to the hospital. The progress note did not indicate the reason for the transfer. A subsequent progress note dated 01/15/24 at 9:40 P.M. revealed Resident #101 had returned to the facility from the hospital, with the emergency medical technician's who transported her back to the facility reporting to facility staff the examination at the hospital was negative. Review of the facility SRI investigations for SRI tracking number #242981 and SRI tracking number #243086 revealed both SRI's were centered around one allegation of alleged staff to resident sexual abuse. The SRI's identifed former State Tested Nurse Aide (STNA) #800 as the alleged perpetrator to the event which happened a few weeks prior. STNA #800 was suspended on 01/11/24 pending the outcome of the investigation. The first SRI report for SRI tracking number 242981 revealed Resident #101 declined to pursue charges against STNA #800. The facility submitted a second SRI #243086 after Resident #101 later changed her mind and wanted to press charges. STNA #800 was suspended for a second time on 01/15/24 and did not return to the facility. The investigative file contained no evidence that like residents were interviewed as part of the investigation. The investigative file did not include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 7 of 15 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 02/08/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few an interview with the alleged perpetrator nor any other staff members as part of the investigation. Both self reported incidents were unsubstantiated by the facility. Interview on 01/30/24 at 11:35 A.M. with Resident #101 revealed Resident #101 recalled the incident from a few weeks back involving former STNA #800. She stated she rolled onto her right side so the aide could provide incontinence care for her, and in the process he put his finger in me vaginally. Resident #101 stated he was the only aide in the room at the time. Resident #101 stated she had trouble processing what happened. Resident #101 admitted she waited approximately two weeks to report the incident to facility staff. Resident #101 stated the former Administrator interviewed her as did a police officer. The night she requested to press charges against former STNA #800, the facility sent her to the hospital but there was no physical examination. Resident #101 stated the only thing the hospital did was ask her questions to make sure I was not out of my mind. Interview on 01/31/24 at 2:02 P.M. with Regional Clinical Manager (RCM) #201 verified the investigation files contained no evidence of staff or resident interviews being completed as part of the investigation. RCM #201 verified the facility should have maintained a list of what residents were interviewed, what questions were asked, and when they were interviewed. RCM #201 verified there should have been staff interviews completed as part of the investigation. RCM #201 stated the former Administrator was in charge of these investigations and no longer worked at the facility. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 10/24/22, revealed once the Administrator and the Ohio Department of Health are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days unless there are special circumstances causing the investigation to continue beyond five working days. The resident, the accused, and all witnesses should be interviewed. Witnesses included anyone who saw or heard the incident, those who came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee or alleged victim the day of the incident. Other health care professionals could be interviewed as appropriate, but all interviewed should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 8 of 15 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 02/08/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and facility policy review, the facility failed to complete wound care as ordered. This affected one (Resident #120) of four residents reviewed for wound care. The facility census was 113. Residents Affected - Few Findings include: Review of the medical record for Resident #120 revealed an admission date of 09/16/23 and discharge date of 12/27/23 with diagnoses including type two diabetes mellitus, non-pressure chronic ulcer of other part of right foot, open wound of right lower leg, peripheral vascular disease, venous insufficiency, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/30/23, revealed Resident #120 had intact cognition. She had a diabetic foot ulcer and moisture associated skin damage (MASD). Review of the plan of care, dated 09/19/23, revealed Resident #120 had the potential for alteration in skin integrity related to immobility, obesity, and her diagnoses. Interventions included administering medications as ordered, administering treatments as ordered, providing the diet according to orders, educating the resident on causes of skin breakdown, monitoring and reporting any suspicious moles and lesions, pain assessment quarterly and as needed, pressure redistribution cushion to chair, skin assessment weekly, and therapy as ordered. Review of the wound documentation, dated 12/05/23, revealed Resident #120 refused wound care treatment in lieu of outpatient wound care treatment. The written measurements obtained from the wound clinic included an area on her right posterior superior medial thigh which was resolving and measured 1.0 centimeters (cm) by 1.2 cm, a diabetic or venous area to her right lateral leg which was stable and measured 5.6 cm by 4.2 cm by 0.2 cm, a diabetic ulcer to her right heel which measured 1.5 cm by 1.7 cm by 0.1 cm, a right great toe diabetic ulcer which measured 3.3 cm by 3.4 cm by 1.1 cm, and MASD to her groin which measured 7.0 cm by 0.5 cm by 0.4 cm. Review of the plan of care, dated 12/11/23, revealed Resident #120 had an alteration in skin integrity to the left upper leg, right lateral leg, and right lateral great toe related to diabetes and noncompliance. Interventions included administering medications as ordered, checking dressing for placement during provision of routine care, documenting wound status weekly and as needed, encouraging her to be out of bed as tolerated, monitoring wound for signs of infection, and providing treatment as ordered. Review of the wound documentation, dated 12/12/23, revealed Resident #120 refused wound care treatment in lieu of outpatient wound care treatment. The written measurements obtained from the wound clinic included that her right posterior superior medial thigh wound had resolved. Her right lateral leg diabetic wound was 4.4 cm by 3.4 cm by 0.1 cm, her right heel wound was healed, her right great toe ulcer had improved and was 3.3 cm by 3.4 cm by 1.1 cm, and her MASD wound to the groin was 5.0 cm by 0.4 cm by 0.3 cm and had improved. Review of the physician order, dated 11/21/23 to 12/11/23, revealed a treatment order for the diabetic ulcer to Resident #120's right lateral leg. The treament included cleansing with Dakins, patting dry, applying hydrocortisone to intact skin, applying triad cream to the area around the wound, covering with ABD pad (absorbent dressing), wrapping with Kerlex, and covering with ACE wrap every (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 9 of 15 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 02/08/2024 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 0684 other day and as needed. Level of Harm - Minimal harm or potential for actual harm Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2023 revealed there was no evidence the wound treamtent to Resident #120's right leg was completed as ordered on and 12/09/23. Residents Affected - Few Review of the progress notes revealed Resident #120 there was no explanation as to why Resident #120's wound care to the right leg was not completed on 12/09/23. Review of the physician order dated 12/08/23 to 12/11/23 revealed an order for treatment to Resident #120's right heel. The treatment included cleansing with normal saline, patting dry, painting with betadine, covering with ABD pad, and securing with kerlix once daily and as needed. Review of the MAR and TAR for December 2023 revealed there was no evidence the wound treatment to Resident #120's right heel was completed as ordered on 12/09/23 and 12/10/23. Additionally, other was indicated for the wound care to Resident #120's right heel on 12/08/23. Review of the progress notes revealed Resident #120 did not receive wound care to her right heel on 12/08/23 because she was in activities. There was no note indicating why her right heel wound treatment was not completed on 12/09/23 and 12/10/23. Review of the physician order, dated 11/27/23 to 12/13/23, revealed an order for a wound treament to Resident #120's right posterior upper thigh. The treament included cleansing with normal saline, patting dry, and applying Z guard every shift and as needed. Review of the MAR and TAR for December 2023 revealed there was no evidence wound treatment to Resident #120's right posterior upper thigh was completed as ordered on day shift on 12/01/23, 12/04/23, 12/09/23, and 12/10/23. Additionally, there was no evidence the wound treatment to Resident #120's right posterior upper thigh was completed on night shift on 12/03/23. Review of Resident #120's progress notes revealed there was no note indicating why the wound treatment to her right posterior upper thigh was not completed on 12/01/23, 12/03/23, 12/04/23, 12/09/23, and 12/10/23. Review of the physician order dated 11/24/23 to 12/11/23 revealed an order for Resident #120's left upper thigh. The treatment included cleansing with Dakins, patting dry, packing with Dakins moistened gauze, covering with ABD pad, and securing with tape every shift and as needed for MASD. Review of the MAR and TAR for December 2023 revealed the Dakins orders for Resident #120's left upper thigh were on both the MARS and TARS. There was no evidence Resident #120's wound treatment to her left upper thigh was completed on day shift on 12/04/23, 12/09/23, and 12/10/23. Additionally, other was marked for the wound treatment on day shift on 12/08/23. Review of the progress notes revealed there was no note indicating why wound treatment to Resident #120's left upper thigh was not completed on 12/04/23, 12/09/23, and 12/10/23. On 12/08/23, it was indicated that wound care was not completed because Resident #120 was in activities. Review of the physician order, dated 11/24/23 to 12/11/23, revealed Resident #120 had an order for wound treatment to the right medial foot. The treatment included cleansing with normal saline, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 10 of 15 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 02/08/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patting dry, applying Dakins moistened gauze, covering with ABD wrap, and wrapping with kerlix every shift and as needed. Review of the MAR and TAR for December 2023 revealed that Dakins orders for Resident #120's right foot were on both the MARS and TARS. There was no evidence the wound treatment to Resident #120's right foot was completed as ordered on day shift on 12/04/23, 12/09/23, and 12/10/23. Additionally, other was marked on day shift on 12/08/23. Review of the progress notes revealed there was no note indicating why wound treatment to Resident #120's right foot was not completed on 12/04/23, 12/09/23, and 12/10/23. On 12/08/23 it was indicated that wound care was not completed because the resident was in activities. Interview on 01/31/24 at 12:51 P.M. and 12:10 P.M. and on 02/01/24 at 10:59 A.M. with Regional Clinical Manager #201 revealed Resident #120 being in activities was not an acceptable reason to miss a dressing change as it could have been done at another time. Regional Clinical Manager #201 reported it did not make sense for Dakins to be done twice a day as had been ordered. She reported some staff had been doing it twice a day and others were only doing it once a day since it did not make sense. Regional Clinical Manager #201 verified there were missing wound treatments for Resident #120. Review of the facility policy titled Skin Care Management, last revised 06/08/22, revealed residents with identified skin breakdown will have a documented skin assessment weekly. Treatments should be completed as ordered and care plans updated as needed. This deficiency represents non-compliance investigated under Master Complaint Number OH00150624, Complaint Number OH00150430, and Complaint Number OH00150281. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 11 of 15 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 02/08/2024 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, resident interview, staff interview, observation, resident family interview, and policy review, the facility failed to ensure central venous line (a type of intravenous access that goes directly into central circulation near the heart) dressing changes were completed as ordered. This resulted in actual harm when Resident #43's central venous line dressing changes were not completed as ordered and Resident #43 was admitted to the hospital on [DATE] with sepsis from a central line-associated blood stream infection. Additionally, the facility failed to ensure peripherally inserted central catheter (PICC) (a type of intravenous access inserted through a peripheral vein which terminates in central circulation near the heart) dressings changes were completed as ordered. This affected two residents (Residents #43 and #130) of four residents reviewed for care of intravenous lines. The facility identified seven residents in the facility with intravenous access. The facility census was 113. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 09/09/19. Resident #43's medical diagnoses included short bowel syndrome, postsurgical malabsorption, chronic respiratory failure, and chronic pain. Review of Resident #43's Annual Minimum Data Set (MDS) assessment, dated 01/12/24, revealed Resident #43 had intact cognition. Resident #43 was not noted to have any hallucinations, delusions, behaviors, or rejection of care. Resident #43 was noted to have intravenous access and receive intravenous medications. Review of Resident #43's hospital paperwork, dated 08/12/23, revealed Resident #43 had a tunneled single-lumen (one intravenous access port) central line that was placed on 01/06/22 at a local hospital by interventional radiology. Resident #43 had the central line throughout the duration of her stay at the facility. Review of Resident #43's discontinued physician orders revealed an order, dated 09/18/22, for Resident #43's central line dressing to be changed daily. The order was discontinued on 08/14/23 while Resident #43 was at the hospital. There was another order placed by the facility Nurse Practitioner on 11/27/23 for central line dressing changes once weekly and as needed. There was no schedule attached to the 11/27/23 order to indicate on which days or shift the treatment should be completed, and the order did not show up on Resident #43's Treatment Administration Record (TAR). There was no order for Resident #43's central line dressing to be changed between 08/14/23 and 11/27/23. Review of Resident #43's TAR for September 2023, October 2023, November 2023, and December 2023 revealed no documentation of any central line dressing changes listed on the TAR. Resident #43's medical record contained no evidence facility staff changed Resident #43's central line dressing from September 2023 through December 2023. Review of Resident #43's progress notes, dated 12/25/23 and timed 11:10 P.M., revealed Resident #43 was found lethargic and unresponsive. She was found to have an oxygen saturation level of 57% (normal value is 90% to 100%). She was placed on supplemental oxygen which began to increase her oxygen saturation level. The provider and a family member were notified, and Resident #43 was transported to a local hospital for further assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 12 of 15 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 02/08/2024 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 0694 Level of Harm - Actual harm Residents Affected - Few Review of Resident #43's hospital records, dated 12/25/23 to 01/05/24, revealed Resident #43 arrived at the emergency department of a local hospital on [DATE] after she appeared to be unresponsive and in respiratory distress at the facility. Resident #43 was found to have sepsis from a central line-associated blood stream infection and was admitted to the Intensive Care Unit (ICU). Resident #43's blood cultures which were drawn at the hospital on [DATE] were positive for enterococcus bacteria in her blood stream and were further confirmed by subsequent sets of blood cultures taken on 12/26/23 and 12/27/23. Resident #43 underwent a procedure performed by interventional radiology to remove her tunneled central line on 12/27/23. She underwent an additional procedure on 01/04/24 per interventional radiology to place a new double lumen central venous line prior to her return to the facility. Resident #43 required intravenous Vancomycin (an antibiotic) throughout the duration of her hospital stay. Resident #43 was discharged back to the facility with a double lumen tunnelled central venous catheter. Review of Resident #43's physician orders upon her return to the facility revealed an order, dated 01/05/24, to continue Vancomycin through 01/11/24. Resident #43's physician orders did not include an order for intravenous dressing changes until 01/16/24 when an order was placed for Resident #43 to have a PICC line dressing and cap changes completed every seven days and as needed. The order for the PICC line dressing was discontinued on 01/23/24 while Resident #43 was at the hospital. Observation on 01/31/24 at 3:04 P.M. with Registered Nurse (RN) #303 revealed Resident #43 had a double lumen central line present to the right chest. Interview on 02/06/24 at 12:31 P.M. with Resident #43 revealed sometimes the nurses changed her dressing. Resident #43 stated in November 2023 and December 2023, the central line dressing did not get changed frequently enough. Resident #43 estimated the central line dressing was changed every few weeks or if it fell off. Interview on 02/06/24 at 12:38 P.M. with RN #320 revealed he primarily worked on the skilled unit on the first floor. RN #320 revealed he was occasionally summoned to another floor or unit to assist with a task or medication that required an RN's skillset. RN #320 stated he was not very familiar with Resident #43's care needs or intravenous access. RN #320 stated when he was needed on other floors, he was alerted by that floor's on-duty nurse that assistance was needed. RN #320 revealed if no one communicated to him that assistance was needed then he would not be aware. Interview on 02/06/24 at 12:50 P.M. with Licensed Practical Nurse (LPN) #301 revealed if she had a medication or task which was out of her scope of practice then she would alert the RN in the building, and they would come to complete the task and would be responsible for completion of the documentation. LPN #301 further explained that if nothing shows up on the Medication Administration Record (MAR) or TAR, then nothing would prompt her that a task, such as a dressing, needed completed. Interview on 02/06/24 at 12:55 P.M. with LPN #205 revealed if one of her residents required a task outside of her scope of practice then she would inform the RN on duty. LPN #205 stated tasks or medications showed up on the MAR or TAR in yellow when they were due, and in red when they were overdue. LPN #205 revealed this alerted the nurse on duty that an order or task needed to be completed. LPN #205 stated if an order did not pop up, it was not due that day. Interview on 02/06/24 at 12:58 P.M. with Regional Clinical Manager (RCM) #201 verified Resident #43's TAR's for September 2023, October 2023, November 2023, and December 2023 contained no evidence that Resident #43's central line dressing was changed by facility nursing staff during those months. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 13 of 15 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 02/08/2024 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 0694 Level of Harm - Actual harm Residents Affected - Few RCM #201 verified the facility Nurse Practitioner inputted the 11/27/23 order for central line dressings incorrectly and the order did not show up on the TAR which was what would have prompted the nurse to change the dressing. RCM #201 verified a nurse placed an order for the wrong type of intravenous line on 01/16/24, which was during the time the facility audited all orders related to intravenous lines and indicated Resident #43's orders were accurate even though they were not. RCM #201 verified Resident #43 should have had orders for central line dressing changes every seven days for the entire time she had her central intravenous access line. 2. Review of the medical record for Resident #130 revealed an admission date of 11/30/23. Resident #130 was transferred to a local hospital following a change in condition on 01/16/24 and did not return to the facility. Resident #130's medical diagnoses included pathological fracture in neoplastic disease of the right humerus, immunodeficiency, need for assistance with personal care, and severe protein-calorie malnutrition. Review of a physician order, dated 11/30/23, revealed Resident #130's PICC line dressing and intravenous caps (needleless adapters) were to be changed every seven days and as needed. The weekly PICC line dressing change was scheduled for Tuesdays on day shift (7:00 A.M. to 3:00 P.M.) and was to be recorded on the resident's TAR. Review of Resident #130's December 2023 MAR revealed the PICC line dressing and cap change was documented as completed on 12/12/23 and 12/19/23. The TAR contained no documentation the PICC line dressing or caps were changed as ordered on 12/05/23 and 12/26/23. Review of Resident #130's January 2024 MAR revealed no documentation that the PICC line dressing or caps were changed as ordered on 01/02/24 and 01/09/24. The 01/16/24 entry on the TAR noted Resident #130 was in the hospital. Interview on 01/29/24 at 2:47 P.M. with a family member of Resident #130 revealed they were present at the hospital on [DATE] with Resident #130. The family member revealed concerns were raised by the hospital staff regarding Resident #130's PICC line dressing being loose and dated 12/27/23 upon her arrival to the hospital. Interview on 02/01/24 at 10:41 A.M. with RCM #201 verified Resident #130's TAR and medical record was missing evidence the PICC line dressing and cap changes were completed at the facility on 12/05/23, 12/26/23, 01/02/24 and 01/09/24. RCM #201 stated the facility had been aware of this incident after receiving negative feedback from a family member. Review of the facility policy titled Central Venous Catheter Care and Dressing Changes policy, revised November 2022, revealed the purpose of the procedure was to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. The policy identified a sterile dressing should be maintained for all central vascular access devices and should be changed when visibly soiled, compromised, and at least every seven days. The policy additionally stated the documentation of the dressing change should be recorded in the resident's medical record. This deficiency represents non-compliance investigated under Master Complaint OH00150624 and Complaint OH00150384. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 14 of 15 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 02/08/2024 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 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 medical record review, observation, resident interview, and staff interview, the facility failed to ensure medications were administered as ordered. This affected one (Resident #101) of five residents reviewed for medication administration. The facility census was 113. Findings include: Review of the medical record for Resident #101 revealed an admission date of 11/28/20. Resident #101's medical diagnoses included multiple sclerosis, muscle weakness, and depression. Review of Resident #101's physical chart on 01/30/24 at 8:10 A.M. revealed a flagged handwritten order from a psychiatric Certified Nurse Practitioner (CNP) for Melatonin three milligrams (mg) daily at bedtime and to add a diagnosis to Resident #101's medical record of hypersomnia (excessive daytime sleepiness). The order for melatonin three mg at bedtime and the diagnosis of hypersomnia were not pressent in Resident #101's electronic health record. Observation on 01/30/24 at 6:44 A.M. revealed Resident #101 in bed with the room lights off. Resident #101 appeared to be asleep. Subsequent observations the on 01/30/24 at 8:16 A.M. and 10:01 A.M. revealed Resident #101 continued to appear to be asleep. Interview on 01/30/24 at 8:39 A.M. with Licensed Practical Nurse (LPN) #205 verified that the flagged order for Melatonin three mg at bedtime in Resident #101's chart, dated 01/23/24, had not yet been transcribed into Resident #101's electonic medical record. LPN #205 verified Resident #101 had not received the Melatonin from 01/23/24 to 01/29/24 as the medication was never input into the electronic health record as an active order. Interview on 01/30/24 at 11:35 A.M. with Resident #101 revealed she has had difficulty sleeping for several weeks. Resident #101 stated she would look at the clock through the night and realize hours had gone by and she would still be awake. She stated she requested something to help her sleep but did not believe the provider had ever ordered anything. Interview on 01/31/24 at 9:40 A.M. with Regional Clinical Manager (RCM) #201 and [NAME] President of Clinical Services (VPCS) #203 revealed the facility did not have a policy for transcribing physician orders but identified the order should be transcribed the same day. Furthermore, RCM #201 stated it was the facility's practice for the providers to input new orders directly into the electronic health record, but there was a fairly new consultant nurse practitioner who did not yet have access to the facility electronic health records system. This deficiency represents non-compliance investigated under Complaint Number OH00150384. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 15 of 15