Health inspection·June 12, 2024

F 0690 Level of Harm - Actual harm Residents Affected - Few Review of Resident #84's admission progress note dated 05/01/24 at 6:37 P.M. revealed the Foley catheter was in place on admission for urine retention and a history of Resident #84 failing a voiding trial while in the hospital. Review of Resident #84's progress note dated 05/03/24 at 12:03 P.M. and authored by the nurse practitioner, revealed Resident #84 had an indwelling urinary catheter for urinary retention and was requesting to have the catheter removed and a voiding trial to be started. The progress notes reflected removal of the catheter and voiding trial to be initiated on 05/07/24. Review of Resident #84's physician orders for May 2024 (after the urinary catheter was removed) revealed a voiding trial every six hours for urinary retention, bladder scan and straight catheter if greater than 350 milliliters (ml) of urine (identified with the bladder scan). Review of Resident #84's Treatment Administration Record (TAR) dated 05/06/24 to 05/10/24 revealed on 05/06/24 Resident #84's indwelling urinary catheter was removed, with a voiding trial to assess if Resident #84 was able to void on her own without the assistance of a urinary catheter. The order included a bladder scan to be completed with the amount of urine identified in the bladder to be documented on the TAR. The voiding trial was to be documented three times per day (every eight hours) and was initiated on 05/06/24 at 6:00 P.M. Further review of the TAR revealed the nurses were writing their initials for the completion of the assessment every eight hours but there was no documentation regarding the amount of urine that was found to be in the bladder, by obtaining a bladder scan, at the time of the completed assessment. Review of Resident #84's bladder tracking documentation, dated 05/06/24, revealed Resident #84's indwelling catheter was removed, and a voiding trial was initiated. Resident #84's bladder tracking was documented as the resident being dry (no urination) three times on 05/07/24 from 6:36 P.M. to 10:28 P.M. and incontinent of urine one time at 11:00 P.M. On 05/08/24 from 12:00 A.M. to 4:00 A.M., the resident's bladder tracking was marked as voided (urinated) without the amount of urine documented, from 5:00 A.M. to 12:32 P.M. Resident #84 was documented as incontinent of urine eight times on 05/08/24 and at 2:58 P.M., Resident #84 voided one time with no amount of urine documented. There were no further entries for Resident #84's bladder tracking dated 05/08/24. On 05/09/24 at 2:31 A.M., Resident #84's bladder tracking was marked as not applicable, the next bladder tracking entry was at 5:34 P.M to 6:00 P.M. and 10:19 P.M. marked as being incontinent. On 05/10/24, Resident #84's bladder tracking was marked as not applicable with the first entry being at 2:59 P.M. Review of Resident #84's care plan, dated 05/08/24, revealed Resident #84 had an alteration in elimination, with an indwelling urinary catheter in place, related to urine retention. Resident #84's interventions included assisting (the resident) with toileting when requested and provide care as needed. Review of Resident #84's progress note, dated 05/10/24 at 1:07 A.M., revealed the resident complained of abdominal pain. The abdomen was firm and distended. A bladder scan and (bladder) catheterization were completed per order. Thirteen hundred milliliters of urine was drained from the bladder. The urine was bloody with mucus/sediment. A new order for a urinalysis with culture and sensitivity was received. The resident's husband was present and aware of the new order. Review of the Nurse Practitioner progress note, dated 05/10/24 at 9:08 A.M., revealed the resident was lying in bed without distress, but has tachycardia (rapid heart rate), hypotension (low blood pressure), lethargy, tachypnea (rapid respirations), catheter tubing with thick, milky, red mucus and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 2 of 14 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 06/12/2024 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 0690 Level of Harm - Actual harm Residents Affected - Few thin, red fluid with thick white tissue in the (bedside catheter drainage) bag. The resident wakes to touch and name, intermittently. The resident's spouse was at bedside and the resident and spouse were educated on the provider's plan to begin antibiotics as well as intravenous (IV) hydration. Understanding and agreement were stated by the resident and spouse. Three nurses attempted to insert an IV but were unsuccessful. The resident stated IVs are always difficult (to insert). The nurse administered an intramuscular dose of antibiotic (Rocephin). The resident's bladder is rigid, the catheter was flushed without full volume return. The catheter was removed to be changed due to sterile compromise. Resident remains tachypneic, hypotensive (no blood pressure readings provided), tachycardic, lethargic and febrile, over 103.0 degrees Fahrenheit, despite axilla ice packs. After approximately two hours, it is necessary to send the resident to the emergency room. Review of Resident #84's re-admission paperwork from the hospital, dated 05/21/24 at 1:17 P.M., revealed to follow up with urology in one week for voiding trial and a diagnosis of sepsis with suspected urology source from a recent urinary tract infection, having completed a course of antibiotic therapy of Zosyn during the hospital stay from 05/10/24 to 05/21/24. Interview on 05/23/24 at 10:42 A.M. with Resident #84 revealed the staff had removed the catheter and then didn't consistently check her output, like they should have. Resident #84 further explained she had been voiding small amounts of urine and then developed lower abdominal pain and distention along with elevated temperature on 05/10/24. Resident #84's spouse was visiting Resident #84 at this time and requested the nurse to assess Resident #84. The nurse assessed the resident, completed a bladder scan and inserted a catheter due to 1,300 ml of urine being drained from the resident's bladder. Interview on 05/23/24 at 2:00 P.M. with Unit Manager (UM) #282 revealed Resident #84 had been admitted to the facility with an indwelling urinary catheter with the catheter being removed on 05/06/24 and a voiding trial initiated with the order to scan the bladder for residual urine and if the amount was greater than 350 milliliters (ml) with the bladder scan, then a bladder catheterization had to be conducted. UM #282 stated she was working as the floor nurse, when on 05/10/24 at 1:03 A.M. she performed a bladder scan and urinary catheterization due to Resident #84's complaint of lower abdominal pain and distention. UM #282 verified there was a total of 1,300 ml of white colored urine removed from Resident #84. Interview on 05/28/24 at 3:03 P.M. with the Director of Nursing (DON) confirmed the voiding trial for Resident #84, dated 05/06/24 to 05/10/24 on the May TAR, revealed the results (of the bladder scan) were not documented despite the order. The DON stated the expectations for the facility nurses were to use the facility's bladder scanners and record the results on the TAR, to accurately monitor for potential urinary retention and address as ordered. Interview on 05/29/24 at 9:50 A.M. with State Tested Nursing Assistant (STNA) #326 revealed Resident #84 did have an indwelling urinary catheter which was removed, and a voiding trial was started. STNA #326 stated Resident #84 would request assistance to the bathroom or would be incontinent of urine with her adult brief being damp or slightly wet. STNA #326 also stated Resident #84 would be dry multiple times during the shift and stated Resident #84 was able to make her needs known but required assistance with transfers and toilet use. Review of the facility's policy titled, Catheter Insertion and Removal (Female) including Bladder Instillation dated 06/08/22 revealed, the purpose for catheter included, to relieve bladder distention, to obtain a specimen for diagnostic purposes, to instill medication into the bladder, and to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 3 of 14 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 06/12/2024 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 0690 determine the amount of residual urine in the bladder after the resident urinates. Level of Harm - Actual harm This deficiency represents non-compliance investigated under Complaint Number OH00154103. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 4 of 14 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 06/12/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and pharmacy contract review the facility failed to ensure a comprehensive medical record review was completed to identify irregularities with prescribed medications during the monthly pharmacy medication regimen review (MRR). This affected one resident (Resident #105) of five residents reviewed for anticoagulant medication use. The facility census was 103. Findings Include: Review of medical record for Resident #105 revealed an initial admission to the facility on [DATE] with diagnoses including a history of stroke, atrial fibrillation (Afib), type two diabetes mellitus, and breast cancer. Further review revealed Resident #105 was dependent on staff for activities of daily living (ADL) tasks and transfers, was non-ambulatory using a wheelchair for mobility and was verbally able to make needs known to staff. Review of Resident #105's care plan, dated 04/13/23, revealed the use of anticoagulant therapy to treat atrial fibrillation with a goal of no adverse effects and interventions included to administer per physician orders and obtain vital signs as necessary. Review of the physician orders revealed an order for Eliquis, initiated on 04/14/23, 2.5 milligrams (mg) twice a day for atrial fibrillation. Review of the Medication Administration Record revealed this medication continued through 02/13/24 when the resident was transferred to the hospital. Review of the Medication Administration Record (MAR) for February 2024 revealed Resident #105 was administered the anticoagulant medication, Eliquis 2.5 mg two times daily from 02/01/24 through the morning dose on 02/12/24. Further review of the closed medical record revealed Resident #105 was hospitalized from [DATE]. Review of the hospital discharge summary and hospital discharge orders dated 02/15/24 revealed an order to increase the anticoagulant medication dose of Eliquis to 5 mg two times daily for atrial fibrillation. Review of Resident #105's medication orders for March 2024, April 2024, and May 2024 revealed no Eliquis orders were initiated or administered for either 2.5 mg or 5.0 mg dosages. Review of the Pharmacy Medication Regimen Review dated 03/09/24 revealed Consulting Pharmacist (CP) #409 reviewed Resident #105's medication orders since readmission to the facility from 02/15/24 to 03/09/24. There were no recommendations or clarifications requested for the physician to address or recommendations for the facility nursing department to address. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of arterial fibrillation and had been previously ordered the medication. Review of the Pharmacy Medication Regimen Review dated 04/16/24 revealed CP #409 had two recommendations. The first was for a gradual dose reduction for Resident #105's prescription for Ambien (medication to treat insomnia). The recommendation was declined by Medical Director (MD) #404. The second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 5 of 14 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 06/12/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for a laboratory test for lipids and for liver function tests, this was approved by MD #404. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of arterial fibrillation and had been previously ordered the medication. Interview on 05/29/24 at 3:14 P.M. with CP #409 revealed completion of the monthly pharmacy medication regimen review involved the review of the documents the facility had uploaded or documented in the electronic medical record (EMR). CP #409 stated diagnoses and medications are reviewed, if there was a diagnosis of atrial fibrillation, then the review would involve a more in-depth look at the ordered medications for appropriateness and accuracy. CP #409 confirmed Resident #105 did have a diagnosis of atrial fibrillation. The pharmacy review did not have documentation to support further review of the resident's cardiac history and no anticoagulant use. Interview on 05/29/24 at 3:55 P.M. with Clinical Services Manager (CSM) #408 confirmed the facility missed the order on readmission of Resident #105 on 02/15/24 and the facility's check and balance systems and consultants did not identify the lack of the Eliquis order for Resident #105, even though she had been receiving the medication prior to the hospitalization on 02/13/24 and the medication was ordered, but with an increased dose, upon her return to the facility on [DATE]. Review of the consulting pharmacist contract dated 01/20/23 revealed, Review each Resident's clinical record monthly and evaluate for appropriateness of the therapy according to current medical practice standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 6 of 14 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 06/12/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, pharmacy medication regimen review, interviews with staff, Medical Director #404, Pharmacy Clinical Director #406, and Family Member #500, review of information on the American Heart Association Website www.heart.org, review of the Eliquis online customer information, and consultant pharmacy contract review, the facility failed to prevent a significant medication error for Resident #105. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #105, who had a history of atrial fibrillation (a condition of rapid heartrate), and cerebral vascular accident (CVA/stroke) did not receive physician ordered anticoagulation therapy (Eliquis) to prevent blood clot formation from [DATE] to [DATE]. On [DATE], Resident #105 was transferred to the hospital with presenting symptoms of facial droop and aphasia (difficulty speaking). The resident was admitted to the hospital on [DATE] with an embolic stroke and subsequently passed away on [DATE] with hospice services. This affected one resident (#105) of five residents reviewed for anticoagulant therapy. The census was 103. Residents Affected - Few On [DATE] at 11:20 A.M., the Administrator and Clinical Services Manager (CSM) #408 were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure hospital orders to increase Resident #105's Eliquis were implemented resulting in a significant medication error. The facility failed to administer the medication between [DATE] and [DATE]. On [DATE], Resident #105 was assessed to have facial drooping and aphasia (difficulty speaking). The resident was emergently transported to the hospital on [DATE] and was admitted due to suffering an embolic stroke. The resident passed away on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 5:35 P.M. Resident #105 was transferred to the hospital for a change in condition. • On [DATE] at 1:10 P.M., the daughter of Resident #105 spoke with Licensed Social Worker (LSW) #246, in person, regarding a status update on the resident and reported a concern that Resident #105 may not have been taking the correct medications (Eliquis). • On [DATE] at 10:00 A.M., Resident #105's daughter came to the facility to collect the resident's belongings and informed Receptionist #292 that the resident had passed away. • On [DATE] at 8:00 A.M., CSM #408 provided in-person and via phone education to all 24 floor nurses including Licensed Practical Nurses (LPN) #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280; Registered Nurses (RNs) #298, #300, #302, #304, #306, #308, #310, and two administrative nurses, RN #296 and the DON, on the policies for order transcription and the admission process/checklist. The admission checklist was updated on [DATE] to include, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 7 of 14 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 06/12/2024 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 0760 not limited to, entering orders from the hospital and admission/readmission orders to the facility. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] at 8:00 A.M., 27 residents (#1, #2, #3, #7, #8, #11, #12, #16, #29, #38, #42, #47, #48, #58, #62, #65, #68, #72, #79, #80, #88, #94, #95, #96, #97, #98, #101) with anticoagulants orders were audited by [NAME] President of Clinical Services (VPCS) #517 and CSM #408 to ensure physicians orders were transcribed correctly with no discrepancies identified. • On [DATE] at 8:00 A.M. all current residents who had been admitted /readmitted to the facility from [DATE] through [DATE] were reviewed on [DATE] to ensure physicians orders were transcribed correctly. Thirty-three admission records were reviewed (#4, #7, #9, #16, #17, #28, #29, #30, #34, #36, #40, #43, #46, #54, #55, #56, #58, #66, #72, #76, #78, #79, #80, #83, #85 #88, #89, #92, #93, #97, #95, #98, #101) and 17 records (#7, #9, #16, #17, #28, #30, #36, #54, #55, #58, #66, #78, #79, #83, #85, #88, #97) had admission orders containing potential discrepancies. Potential discrepancies were between the hospital discharge orders and what was entered into the electronic medical record. The DON clarified these discrepancies with Nurse Practitioner (NP) #402 and orders were correctly transcribed. There were no negative outcomes because of the discrepancies. • On [DATE] at 8:30 A.M., upon Quality Review of Resident #105's medical record completed by CSM #408, the root cause analysis identified that a transcription error had occurred during the readmission of Resident #105 on [DATE]. Eliquis had been increased during Resident #105's hospitalization but the order wasn't transcribed during readmission. • On [DATE] at 10:00 A.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting was held with the Administrator, DON, CSM #408, VPCS #517, Unit Manager #282, Assistant Director of Nursing (ADON), RN #312, and Medical Director #404 (via telephone), to review the root cause analysis completed by CSM #408 and the system in place to ensure that residents receive medications as ordered by the physician and to meet their total care needs. Policies reviewed were the electronic health record Order Entry Transcription and admission Checklist. The checklist had been updated on [DATE] to include, but not limited to, entering orders from the hospital and admission/readmission orders to the facility. • Beginning [DATE], the DON/Designee will complete a comprehensive medication order review of all residents who are admitted /readmitted to the facility within 24 hours of arrival. Medication order review will include verification of accurate transcription and implementation of medications, and proper medication administration of ordered medications. Ad Hoc education will be completed as indicated. • On [DATE] at 12:30 P.M., an Ad Hoc QAPI meeting was completed with the Administrator, DON, CSM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 8 of 14 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 06/12/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety #408, VPCS #517, Unit Manager #282, RN #296, RN #312, and Medical Director #404 to re-evaluate the system implemented on [DATE] to ensure that residents received medications as ordered by the physician and to meet their total care needs. No changes were made, and policies and process remained appropriate. • Residents Affected - Few On [DATE] starting at 6:45 A.M., licensed nurses were re-educated on the policies and procedures for transcription of medication orders and the admission checklist to ensure continuity of care by the DON/Designee. Education completed included 24 licensed nurses including LPNs #248, #250, #252, #254, #256, #258, #260, #262, #264, #266, #268, #270, #272, #274, #276, #278, #280 and RNs #298, #300, #302, #304, #306, #308, and #310. Agency staff will receive education prior to their next scheduled shift. All newly hired licensed nurses will receive this education during orientation. • On [DATE] at 9:00 A.M., Consultant Pharmacist (CP) #409 remotely completed a comprehensive medication regimen review for all residents admitted /readmitted from [DATE] through [DATE] which included Residents #9, #95, #101, #107, #108, #109, #110, #111 and #112 to determine medication compliance and ensure continuity of care. No discrepancies were identified. • On [DATE] at 9:00 A.M., Pharmacist #516 was educated by Chief Nursing Officer (CNO) #515 regarding the expectation of a comprehensive medication regimen review. • On [DATE] at 12:30 P.M., CNO #515, via phone, educated CP #409 regarding a comprehensive medication review and the facility will ensure all needed documents for a comprehensive review will be uploaded into the electronic health record within 24-72 hours after admission/re-admission. • On [DATE] at 12:45 P.M., an Ad Hoc Resident Council Meeting was held with Activities Director #200, the Administrator and eight residents to review the order transcription and admission checklist process. Residents in attendance were #24, #23, #12, #72, #27, #71, #94, and #25. Resident Council verbalized understanding. • Beginning [DATE], CP #409 will ensure the completion of a comprehensive medical record review to determine medication compliance, which supports continuity of care, within 24-72 hours of resident admission/re-admission to the facility. The facility will ensure within 24-72 hours of admission, the admission documents are uploaded into the electronic medical records. This will be completed by Medical Records #286/designee. All elements of the abatement plan were implemented by [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 9 of 14 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 06/12/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: Residents Affected - Few Review of the closed medical record for Resident #105 revealed an initial admission to the facility on [DATE] with medical diagnoses including history of stroke, atrial fibrillation (AFib), type two diabetes mellitus, and breast cancer. Further review revealed Resident #105 was dependent on staff for activities of daily living (ADL) tasks and transfers, was non-ambulatory using a wheelchair for mobility and was verbally able to make needs known to staff. Review of Resident #105's care plan, dated [DATE], revealed anticoagulant therapy to treat arterial fibrillation with a goal of no adverse effects and interventions to administer per physician orders, and obtain vital signs as necessary. Review of the physician orders revealed an order for Eliquis, initiated on [DATE], 2.5 milligrams (mg) twice a day for atrial fibrillation. Review of Resident #105's quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (out of a score of 15), Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N - Medications marked for use of an anticoagulant medication. Review of the February 2024 Medication Administration Record (MAR) revealed Resident #105 was administered the anticoagulant medication Eliquis 2.5 mg two times daily from [DATE] to the morning dose on [DATE]. Review of the progress note dated [DATE] at 2:22 P.M., authored by Licensed Practical Nurse (LPN) #276, revealed Resident #105 had chief complaint of abdominal pain and stated she had suicidal ideations and verbalizations. LPN #276 notified the certified nurse practitioner (CNP) (unidentified) and received an order to send Resident #105 to the hospital emergency department for evaluation. LPN #276 notified Resident #105's power of attorney (POA) of the new order and transfer of Resident #105 to the hospital. The resident was hospitalized through [DATE] with Influenza A. Review of the hospital discharge summary and hospital discharge orders, dated [DATE], revealed an order to increase the anticoagulant medication dose of Eliquis to 5 milligrams (mg) two times daily for atrial fibrillation. Review of Resident #105's progress notes, dated [DATE] at 8:05 P.M. and authored by LPN # 256, revealed Resident #105 was re-admitted from the hospital with the diagnosis of influenza A. All admission conditions and orders were reviewed and clarified by the on-call physician (unidentified). Review of the MAR dated [DATE] through [DATE] revealed no evidence the anticoagulant medication Eliquis for either the previous dosage of 2.5 mg twice a day or for the new increased dosage of 5 mg twice a day was noted as ordered upon discharge from the hospital on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 10 of 14 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 06/12/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the pharmacy dispensing report for February 2024 revealed Eliquis 5 mg was not delivered by the facility pharmacy during the time span from [DATE] through [DATE]. Review of Resident #105's quarterly MDS Assessment, dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N Medications was not marked for use of an anticoagulant medication. Review of Resident #105's MAR dated [DATE], [DATE], and [DATE] revealed there were no orders for Eliquis at either the previous dosage of 2.5 mg or the new ordered dose of 5 mg. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 reviewed Resident #105's medication orders since readmission to the facility on [DATE] to [DATE]. There were no recommendations or clarifications requested for the physician to address or recommendations for the facility nursing department to address. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of arterial fibrillation and had been previously ordered the medication. Review of the Pharmacy Medication Regimen Review dated [DATE] revealed CP #409 had two recommendations. First, for a gradual dose reduction for Resident #105's prescription for Ambien (medication to treat insomnia). The recommendation was declined by Medical Director (MD) #404. Second, for a laboratory test for lipids and for liver function tests, which was approved by MD #404. There was no indication CP #409 identified Resident #105 was not receiving either the previous dose or the newly ordered dose of Eliquis, even though Resident #105 had the diagnosis of atrial fibrillation or had been previously ordered the medication. Review of the Resident #105's annual MDS assessment dated [DATE] revealed Section C - Cognitive Patterns marked as Resident #105 was cognitively intact with a BIMS score of 15, Section I - Active Diagnoses marked with an active diagnosis of longstanding persistent atrial fibrillation, and Section N Medications was not marked for use of an anticoagulant medication. Review of Resident #105's progress note dated [DATE] at 7:50 P.M., authored by LPN #252, revealed Resident #105's daughter was visiting, and Resident #105 was having difficulty responding to conversation during the daughter's visit. At the time of the transfer (to the hospital) Resident #105's blood pressure was 148/106 millimeters of mercury (mmHg), blood oxygen saturation level was 91 percent (%) with two liters of oxygen in place, and heart rate was 73 beats per minute. Review of the Stroke Network Virtual Neurology Assessment note dated [DATE] at 9:19 P.M. authored by Neurology Physician #512 (part of the resident's hospital record beginning on [DATE]) revealed Resident #105 with history of left frontal lobe ischemic infarction (stroke) with hemorrhage in 2018 resulting in aphasia (inability to speak) which has resolved, and diagnosis of arterial fibrillation prescribed Eliquis but unclear if Resident #105 is receiving the medication or not. Per the nursing facility, Resident #105 was taken off the Eliquis for reason as being unsafe for Resident #105 to be on the Eliquis. There was no additional information about what unsafe meant. Review of the Neurocritical Care History and Physical progress note dated [DATE] at 5:12 A.M. authored by hospital Neuro-physician #510 revealed Resident #105 arrived at the emergency department on [DATE] presenting with right facial droop, right sided weakness, non-verbal, and left gaze preference. Multimodal imaging results showed occlusion of the distal left internal carotid artery and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 11 of 14 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 06/12/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few occlusion in the left and proximal left branches of the internal carotid artery. Resident #105 was not a candidate for thrombolytic (clot buster) interventions due to unclear if Resident #105 was receiving Eliquis prior to emergency department transfer. Further review of the hospital record revealed the resident was taken to the cardiovascular laboratory (lab) for a thrombectomy (removal of the clots), but the catheters were unable to be advanced for removal and the procedure was aborted. Review of the hospital progress note dated [DATE] at 10:16 A.M., authored by Hospital Physician #410, revealed Resident #105 experienced an acute ischemic stroke with Computed Tomography (CT) Scan results which showed large left hemispheric region of the brain with ischemia (an area of the body that is not receiving blood and oxygen due to an occlusion) and associated swelling. Resident #105 also had acute metabolic encephalopathy (a change in the brain which affects how thinking and reasoning occurs and can be caused by a stroke), and acute hypoxic respiratory failure likely related to the ischemic stroke. Resident #105 was placed on palliative and comfort care due to her critical condition and worsening mental status. Resident #105 ultimately expired on [DATE]. Interview on [DATE] at 10:20 A.M. with Family Member #500 revealed Resident #105 had been ordered Eliquis for the treatment of atrial fibrillation since Resident #105's previous stroke which occurred in 2018. Family Member #500 was unsure why Resident #105 had not been placed back on the Eliquis when she was readmitted to the facility on [DATE]. Family Member #500 verified, prior to the stroke team attempting thrombolytic interventions, the emergency room physician questioned if Resident #105 was receiving Eliquis at the facility, but the family member was unsure as to why the resident was not receiving the Eliquis. Interview on [DATE] at 2:15 P.M. with Pharmacy Clinical Director #406 revealed there was no readmission order received from the facility for Resident #105's anticoagulant medication Eliquis when the dose was increased. Pharmacy Clinical Director #406 stated the last fill and dispense for Resident #105's anticoagulant medication, Eliquis 2.5 mg, was on [DATE]. There was no further filled or dispensed anticoagulant medications for Resident #105 from [DATE] to when Resident #105 was admitted to the hospital on [DATE]. Interview on [DATE] at 3:03 P.M. with the DON revealed the expectation for the nurses was to review and clarify medication orders with the physician upon admission or readmission to the facility. Once the orders had been reviewed and approved, the nurses were to transcribe the orders into Point Click Care (the computerized medical record). The DON confirmed there was not an anticoagulant medication order for Resident #105 since readmission to the facility on [DATE] despite the hospital order upon the resident's discharge from the hospital. The DON confirmed Resident #105 had been receiving Eliquis at 2.5 mg since the initial admission on [DATE] and there was no clarification or reasoning for the discontinuation of the Eliquis of the previous dose or on the new dose ordered upon readmission on [DATE]. Interview on [DATE] at 2:25 P.M. with Medical Director (MD) #404 revealed, on admission or re-admission of residents, MD #404 would review the admitting orders from the hospital, which was the source for approving, clarifying, or discontinuing medication orders. The physician shared the only reason he could think of the resident's Eliquis was being held or not administered would be for a breast biopsy due to her recent diagnosis of breast cancer but, even then the Eliquis would have been resumed and not held for three months. Resident #105 should have been on the Eliquis just due to history of an ischemic stroke and having atrial fibrillation. MD #404 shared there was a 20% chance of developing an embolus (clot) once the medication has been discontinued. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 12 of 14 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 06/12/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on [DATE] at 3:14 P.M. with CP #409 revealed completion of the monthly pharmacy medication regimen review involved the review of what the facility had uploaded or documented in the computerized medical record. CP #409 stated diagnoses and medications were reviewed and if there was a diagnosis of atrial fibrillation then the review would involve a more in-depth look at the ordered medications for appropriateness and accuracy. CP #409 confirmed Resident #105 did have a diagnosis of atrial fibrillation, but the pharmacy review did not have documentation to support further review of the resident's cardiac history and no anticoagulant use. Interview on [DATE] at 3:35 P.M. with LPN #256, the admitting nurse for Resident #105 on [DATE], revealed LPN #256 did not recall the details of Resident #105's readmission to the facility on [DATE]. Interview on [DATE] at 3:55 P.M. with CSM #408 revealed the facility missed the order on readmission for Resident #105 on [DATE] and the facility's check and balance systems and consultants did not identify the lack of the Eliquis order for Resident #105, even though she had been receiving the medication prior to the hospitalization on [DATE]. CSM #408 verified the resident returned to the hospital on [DATE] due to experiencing a stroke and expired in the hospital on [DATE]. Review of the consulting pharmacist contract dated [DATE] revealed, review each resident's clinical record monthly and evaluate for appropriateness of the therapy according to current medical practice standards. Review of the American Heart Association website, www.heart.org, defined atrial fibrillation as a quivering or irregular heartbeat, or arrhythmia. Atrial fibrillation, also known as AFib or AF, can lead to blood clots, stroke, heart failure and other heart-related complications. Normally, your heart contracts and relaxes to a regular beat. In AFib, the upper chambers of the heart, or the atria, beat irregularly. Because not enough blood is being pumped out of the atria, blood pools in the area. The pooled blood can clot - which can be extremely dangerous. If a blood clot forms, it can be pumped out of the heart to the brain. This blocks the blood supply to the brain and causes a stroke. About 15% to 20% of people who have strokes have this heart arrhythmia. The clot risk is why patients with this condition are prescribed blood thinners. Some medications are commonly called blood thinners because they can help reduce a blood clot from forming. There are two main types of blood thinners that patients commonly take: anticoagulants such as warfarin, dabigatran (Eliquis) and rivaroxaban (Xarelto), and antiplatelet drugs such as aspirin or clopidogrel. Each type of medication has a specific function to prevent a blood clot from forming or causing a blocked blood vessel, heart attack or stroke. Untreated AFib doubles the risk of heart-related deaths and is associated with a fivefold increased risk for stroke. Yet many people are unaware that AFib is a serious condition. Review of the Eliquis Customer Website, www.eliquis.bmscustomerconnect.com, revealed Eliquis use can reduce the risk of stroke and blood clots in people who have atrial fibrillation (AFib), a type of irregular heartbeat, not caused by a heart valve problem. For patients taking ELIQUIS for atrial fibrillation: stopping ELIQUIS increases your risk of having a stroke. Do not stop taking ELIQUIS without talking to the doctor who prescribed it to you. This deficiency represents non-compliance investigated under Complaint Number OH00154096. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 13 of 14 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 06/12/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview the facility failed to ensure medications were handled and distributed in a sanitary manner. This affected two residents (#12, #25 and #34) out of four residents observed during medication administration. The facility census was 103. Residents Affected - Few Findings Include: 1. An observation on 06/03/24 from 8:45 A.M. to 9:03 A.M. revealed Licensed Practical Nurse (LPN) #264 performing medication administration for Residents #12, and #25. LPN #264 prepared Resident #12's morning medication at the medication cart, knocked and entered Resident #12's room and administered the medication. Upon completion of Resident #12's medication administration, LPN #264 exited the room without washing or sanitizing his hands. Once LPN #264 returned to the medication cart and began preparing Resident #25's medication without sanitizing his hands. LPN #264 completed preparation of Resident #264's medication, LPN #264 knocked and entered Resident #25's room and administered the medication. LPN #264 then exited Resident #25's room without washing or sanitizing his hands. An interview on 06/03/24 at 9:03 A.M. with LPN #264 verified he did not wash his hands between Resident #12's medication and Resident #25's medication administration. LPN #264 stated, he will wash hands halfway through the medication administration time and will sometimes sanitize his hands but he does not perform hand hygiene between each resident medication administration. 2. An observation on 06/03/24 from 8:45 A.M. to 9:03 A.M. revealed Licensed Practical Nurse (LPN) #264 performing morning medication administration for Residents #12, #25, and #34. During the medication administration for each Resident #12, #25, and #34, LPN #264 would shake out the over-the-counter medication into the bottle lid and then placed the medication into the medication cup for Resident #12 #25, and #34 during separate medication administration for each resident. When LPN was removing the prescription medications from the medication storage cards, for Residents #12, #25, and #34, LPN #264 would remove the medications from the cards by popping the plastic blister pocket into his ungloved hand and then LPN #264 would place the medication into each medication cup. This was done during the medication administration for each resident. An interview on 06/03/24 at 9:03 A.M. with LPN #264 confirmed Residents #12, #25, and #34's medications were handled by an ungloved hand, placed in the medication cup, and administered to Resident #12, #25, and #34. LPN #264 stated it is more secure to place the medication in his hand and then into the medication cup, then to try and pop it out of the plastic blister pocket into the medication cup. Review of the facility's policy titled, Medication Administration - General Guidelines dated 12/20/19 revealed, The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, before and after administration of ophthalmic, topical, vaginal, rectal, and parental preparations, and before and after administration of medications via enteral tubes FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366418 If continuation sheet Page 14 of 14