Health inspection·December 2, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete refused the medication. Furthermore, Resident #220 stated, If something isn't done right or there is a refusal of services for me, then I get very upset and it causes me a lot of stress. I feel like the communication is a struggle on a daily basis.Interview on 12/02/25 at 9:15 A.M. with Resident #220's daughter stated she had told management and staff several times to use the translator app and communicate with Resident #220, but still communication was a problem. Furthermore, Resident #220's daughter stated the staff were not assisting Resident #220 with care because of communication issues.Interview on 12/02/25 at 9:30 A.M. with Licensed Practical Nurse (LPN) #185 stated Resident #220 spoke a little English. LPN #185 stated the staff use a translator app on the phone and if that does not work, then they call Resident #220's daughter to communicate with Resident #220.Interview on 12/02/25 at 11:18 A.M. with UM #595 stated all the CNAs and nurses have the translator app on their personal phones and use it to communicate with Resident #220. Furthermore, UM #595 stated the translator access number posted in Resident #220's room was for an on-site translator which can take some time getting to the facility which was why she called Resident #220's daughter to translate that morning.Interview on 12/02/25 at 11:27 A.M. with CNA #280 stated she did not have the translator app on her phone and stated she used hand gestures and simple English phrases to communicate with Resident #220.Interview on 12/2/25 at 11:29 A.M. with LPN #185 who stated she did not have the translator app on her phone. Additionally, LPN #185 stated she takes medication to Resident #220 three times a day and stated she only uses the translator app if her simple hand gestures are not effective at communication. Furthermore, LPN #185 verified Resident #220 had medication which should be taken 30 minutes before meals and stated that if the medications are given to Resident #220 with her meals, then Resident #220 refused to take them.Interview on 12/02/25 at 11:58 A.M. with the Administrator stated the staff communicate with Resident #220 through her daughter and Resident #220's daughter comes to the facility whenever they ask her to.Interview on 12/02/25 at 12:57 P.M. with the Director of Nursing (DON) stated Resident #220 uses her own phone and texts on the translator app, then hands the phone to the staff. Additionally, the DON stated the interpreter line in Resident #220's room was only verbally via the phone and since Resident #220 was hard of hearing, then the staff use the translator app or call Resident #220's daughter to translate.Review of the facility policy titled, Communication Barriers, dated 03/10/25, revealed it is the policy of the facility to take reasonable steps to ensure that residents with communication barriers have access and equal opportunity to participate in meaningful conversations about their medical care, services, treatment, and activities in the facility. Additionally, the facility policy revealed the facility will provide communication assistance by utilizing communication aids, which may include but is not limited to a communication boards, dry erase boards, paper and pen or pencil, magnifying glass, large print, braille, assistive technology or translation applications, staff interpreter, and contracted third party interpreters or translators with no cost to the resident being served. Furthermore, the policy revealed family members or friends will not be used as interpreters unless specifically requested by the resident and only after the resident has been offered an interpreter at no charge to them.This deficiency was issued relative to incidental findings that were discovered during the complaint investigation. Event ID: Facility ID: 366435 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital documentation review, review of an incident report, review of staff training documentation, staff interview, and policy review, the facility failed to ensure residents were administered antibiotic medications and insulin as ordered and within scheduled time frames which resulted in significant medication errors. This affected two (#299 and #45) of six residents reviewed for medication administration. The census was 111.Findings include: 1. Review of the medical record for Resident #299 revealed an admission date of 09/12/25 with diagnoses including pseudomonas as the cause of diseases, gastrointestinal hemorrhage, acute pyelonephritis, and presence of urogenital implants. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #299 was cognitively intact, required setup or clean-up assistance with eating, and was taking an antibiotic and intravenous (IV) medication.Review of a hospital hard script copy dated 09/08/25 and signed by a physician revealed Resident #299 had an order for the antibiotic cefepime four (4) grams intravenous (IV) daily as a continuous 24-hour infusion through 09/18/25.Review of Resident #299's hospital after visit summary dated 09/12/25, for a hospital stay between 09/02/25 and 09/12/25, revealed a medication order to start cefepime 4 grams IV continuous 24-hour infusion through 09/18/25, with the dose to be given every shift.Review of Resident #299's physician order dated 09/12/25 at 11:47 P.M., created by Licensed Practical Nurse (LPN) #720, revealed cefepime hydrogen chloride IV solution reconstituted, two (2) grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of an incident report dated 09/12/25 revealed Resident #299 was ordered continuous IV infusion, but it was entered as twice a day and every shift without directions to run as continuous infusion. Antibiotics were administered each shift instead of continuously. Education was provided to prevent recurrence.Review of Resident #299's physician order dated 09/13/25 revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of Resident #299's medication administration record (MAR) revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day was administered on 09/13/25 at 9:00 A.M. and 9:00 P.M., on 09/14/25 at 9:00 A.M. and 9:00 P.M., and on 09/15/25 at 9:00 A.M.Review of a physician visit document dated 09/14/25 revealed the plan for Resident #299 showed infectious disease was following and recommended continuous IV cefepime. Follow-up with infectious disease was scheduled for 09/16/25 due to a left renal abscess.Review of Resident #299's physician order dated 09/15/25, completed by Unit Manager (UM) #295, revealed cefepime hydrogen chloride IV solution reconstituted, 2 grams, 2 times a day at 9:00 A.M. and 9:00 P.M. was ordered.Review of the MAR revealed on 09/15/25 at 9:00 P.M. and on 09/16/25 at 9:00 A.M., Resident #299 received 2 doses of the antibiotic scheduled for two times a day.Review of Resident #299's physician order dated 09/16/25 revealed an appointment was scheduled with infectious disease.Review of Resident #299's infectious disease note dated 09/16/25 revealed the resident's daughter reported antibiotics were not being given as a continuous infusion as ordered. The physician contacted the extended care facility and staff were unclear why the antibiotics were entered incorrectly and signed by the physician. The plan revealed the culture was positive for a multiple drug-resistant organism (MDRO) due to pseudomonas. Cefepime was supposed to be a continuous infusion. The discharge prescription was written that way, but the facility incorrectly ordered 2 grams, 2 times per day.Review of Resident #299's progress note dated 09/16/25 at 2:43 P.M. revealed the resident returned from the appointment with new orders.Review of Resident #299's progress note dated 09/16/25 at 7:03 P.M. revealed the Power of Attorney (POA) was in the facility and was made aware that new IV antibiotic orders were in place and the pharmacy would deliver the medication.Review of Resident #299's physician order dated 09/17/25 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy 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 - Minimal harm or potential for actual harm Residents Affected - Few through 09/26/25 revealed an order for cefepime hydrogen chloride 4 grams IV for a kidney infection until 09/26/25 as a continuous infusion over 24 hours.Review of Resident #299's MAR revealed cefepime hydrogen chloride 4 grams IV for kidney infection until 09/26/25 as a continuous infusion over 24 hours. The first administration was on 09/17/25 at 9:00 A.M. Interview on 12/01/25 at 2:45 P.M. with the Director of Nursing (DON) and the Administrator confirmed a medication error occurred for Resident #299 when the antibiotic (cefepime) was not administered as continuous and was only a short infusion. The error was identified on 09/16/25 after a new order was received from infectious disease. The DON and the Administrator stated education was completed with all licensed nursing staff. The DON confirmed admitting nurses are responsible for entering orders and a second nurse completed a verification.Interview on 12/02/25 at 10:35 A.M. with UM #140 revealed the admitting nurse was responsible for entering physician orders and a second nurse was to verify to make sure the orders were correct.Interview on 12/02/25 at 10:58 A.M. with UM #295 confirmed Resident #299 was in her assigned hallway. UM #295 denied involvement in the incorrect antibiotic order and denied completing the second medication check.Interview on 12/02/25 at 11:10 A.M. with Licensed Practical Nurse (LPN) #720 confirmed she admitted Resident #299 to the facility and remembered calling the physician office to confirm the antibiotic order. LPN #720 stated prior to the telephone call, she was not aware of any medication errors involving Resident #299. LPN #720 denied receiving education following the incident with Resident #299's antibiotic.Interview on 12/02/25 at 1:17 P.M. with Registered Nurse (RN) #830 could not recall specifics about Resident #299's antibiotic order and denied hearing of any errors. RN #830 confirmed she did not receive any education after the incident involving Resident #299's medication error.Review of an education/training sign-in document dated November 2025 for education on the medication error policy revealed the training covered proper entry of medications in the facility electronic medical record system (Point Click Care) for IV and oral medications. Further review revealed LPN #720 and RN #830 were not listed as attending the training.Interview on 12/02/25 at 1:18 P.M. with the DON confirmed both RN #830 and LPN #720 were not listed as attending the education completed for the medication error involving Resident #299.Review of a medication error policy, dated 08/23/23, revealed a medication error was a failure to follow physician orders, manufacturer specifications, or accepted professional standards. When a resident receives a new medication, the order is evaluated to ensure the dose, route, duration, and monitoring align with clinical practice, guidelines, or manufacturer specifications.2. Review of the medical record for Resident #45 revealed an admission date of 09/09/25 with diagnoses including type two diabetes mellitus, hypertension, cardiomegaly, chronic respiratory failure with hypoxia, chronic diastolic heart failure, and chronic kidney disease. Review of an admission MDS assessment dated [DATE] revealed Resident #45 was cognitively intact and received insulin.Review of Resident #45's physician orders revealed an order dated 09/10/25 for the resident to receive insulin lispro per sliding scale subcutaneously before meals for diabetes mellitus. Review of the MAR for November 2025 revealed Resident #45's sliding scale insulin orders were scheduled to be given daily at 7:30 A.M., 11:30 A.M., and 4:30 P.M. Further review revealed the resident received insulin late on 22 occasions during the month. The late administrations occurred on the following dates and times: on 11/01/25, a dose due at 7:30 A.M. was given at 8:54 A.M. On 11/05/25, a dose due at 11:30 A.M. was administered at 1:06 P.M. On 11/06/25, a dose due at 7:30 A.M. was given at 10:35 A.M. On 11/07/25, a dose due at 7:30 A.M. was administered at 8:40 A.M. On 11/08/25, a dose due at 7:30 A.M. was given at 9:20 A.M. On 11/10/25, a dose due at 7:30 A.M. was administered at 10:33 A.M. On 11/12/25, a dose due at 7:30 A.M. was given at 10:28 A.M. On 11/14/25, a dose due at 7:30 A.M. was given at 8:54 A.M. On 11/15/25, a dose due at 7:30 A.M. was given at 8:57 A.M. and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366435 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366435 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grand The 4500 John Shield Pkwy 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete another dose due at 4:30 P.M. was administered at 6:23 P.M. On 11/16/25, a dose due at 7:30 A.M. was given at 9:02 A.M. On 11/19/25, a dose due at 7:30 A.M. was administered at 11:27 A.M. On 11/20/25, a dose due at 7:30 A.M. was given at 10:19 A.M. On 11/21/25, a dose due at 7:30 A.M. was given at 8:54 A.M. and another dose due at 4:30 P.M. was administered at 6:24 P.M. On 11/22/25, a dose due at 7:30 A.M. was given at 9:18 A.M. On 11/23/25, a dose due at 7:30 A.M. was given at 9:32 A.M. and another dose due at 11:30 A.M. was administered at 1:19 P.M. On 11/26/25, a dose due at 7:30 A.M. was given at 10:46 A.M. On 11/29/25, a dose due at 7:30 A.M. was administered at 9:29 A.M. On 11/30/25, a dose due at 7:30 A.M. was given at 9:26 A.M.Interview on 12/02/25 at 9:14 A.M. with LPN #25 confirmed the late insulin administrations for Resident #45 noted on the November 2025 MAR as listed above. LPN #25 acknowledged administering some of the doses, but denied giving them late. She stated insulin was a priority medication and was never missed or delayed, and explained they have an hour before and after the scheduled time to give. LPN #25 explained the discrepancies may have been due to delayed documentation, as she previously charted after completing all medication passes rather than in real time. LPN #25 confirmed nursing staff recently received education pertaining to documenting medications in real time. Interview on 12/02/25 at 10:35 A.M. with UM #140 revealed she was not aware of concerns related to late medication administration; however, she confirmed there were timing issues noted on Resident #45's November 2025 MAR. UN #140 stated it appeared to be a documentation issue and nursing staff should be signing off insulin administration in real time, which did not occur for Resident #45 on the above dates and times.Interview on 12/02/25 at 11:35 A.M. with the DON confirmed medications should be documented in real time.Review of the medication administration policy, dated 08/07/23, revealed medications administered are documented following administration. Medications can be administered within a two hour time frame (one hour before to one hour after the time prescribed by the physician). Medications specifically ordered AC (ante cibum; before meals) or PC (post cibum; after meals) must be administered as such or will be considered a medication error.This deficiency represents non-compliance investigated under Master Complaint Number 2639073 and Complaint Number 2620502. Event ID: Facility ID: 366435 If continuation sheet Page 5 of 5