Health inspection·March 11, 2020

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the resident assessment indicator (RAI) 3.0 manual the facility failed to complete a significant change assessment after Resident #9 was admitted to end of life (Hospice) services. This affected one Resident (#9) of three reviewed for Hospice services. The facility census was nine. Residents Affected - Few Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including urinary tract infection, major depressive disorder, hypertension, hyperlipidemia, arthritis, dementia, and diabetes mellitus. Review of physician orders dated 02/14/20 revealed the resident was admitted to Hospice for end of life services. Review of the Minimum Data Set (MDS) 3.0 assessments revealed there was no significant change assessment completed within 14 days after Resident #9 was admitted to Hospice services. Interview on 03/10/19 at 1:48 P.M. with the Director of Nursing (DON) revealed Resident #9 did not have significant change assessment completed. The DON verified according to the MDS 3.0 manual the significant change assessment should have been completed within 14 days of the resident's admission to Hospice services. Review of the RAI 3.0 manual revealed a significant change assessment must be completed within 14 days of an admission to Hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366470 If continuation sheet Page 2 of 6 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 366470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and medical record review the facility failed to ensure fall interventions were in place for Resident #113. This affected one (Resident #113) of four residents reviewed for accidents. The facility census was nine. Findings include: Review of Resident #113's medical record revealed an admission date of 02/29/20 with diagnoses including hypertension, fracture of the right femur due to a fall, and dementia without behavioral disturbances. Review of Resident #113's baseline care plan dated 02/29/20 revealed Resident #113 was at risk for falls due to a history of falls in the community. Interventions to prevent falls included, a low bed, fall mats, and non-slip socks. Review of Resident #113's Fall Risk Assessment completed for 03/02/20 revealed Resident #113 was at a high risk for falls due to a history of falls in the community which resulted in a fracture of her right femur. Review of Resident #113's admission medicare 5 day Minimum Data Set (MDS) 3.0 dated 03/06/20 revealed a Brief Interview for Mental Status (BIMS) score of 09. Resident #113 required two staff assistance for bed mobility, transfers, dressing, and toilet use. Multiple observations from 03/09/20 through 03/11/20 between 10:00 A.M. and 4:30 P.M. revealed Resident #113's bed was not in the lowest position at any time, there were no floor mats beside resident's bed or in her room and the resident did not have non-slip socks on at any time during these observations. On 03/11/20 at 12:00 P.M. the Director of Nursing (DON) confirmed Resident #113's fall interventions were not in place at anytime during the above noted observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366470 If continuation sheet Page 3 of 6 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 366470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, observation, staff interview and review of facility policy the facility failed to ensure Oxygen administration tubing was properly labeled to indicate the date. This affected two (Residents #9 and #161) of two residents reviewed for respiratory care services. The facility identified five residents receiving oxygen. The facility census was nine. Residents Affected - Few Findings include: 1. Review of Resident #9's medical record revealed an admission date of 02/11/20 and re-admission on [DATE] with diagnoses including type two diabetes mellitus, acute and chronic respiratory failure, cerebral infarction, psychosis, end stage renal disease, anemia, hypothyroidism, and hypertension. Review of Resident #9's care plan dated 02/14/20 revealed the resident was at risk ineffective breathing patterns secondary to acute respiratory failure, with interventions including to administer oxygen as prescribed. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required total assistance of two persons for transfers and toilet use; extensive assistance of two-persons for bed mobility and dressing; and extensive assistance of one-person for eating. Review of Resident #9's physician's order dated 03/09/20 revealed an order for oxygen administration via a nasal cannula at two liters per minute for an oxygen saturation level of less than 90% and as needed for hypoxia (lack of adequate oxygenation). Observation of Resident #9 on 03/09/20 at 11:54 A.M. revealed the resident had a nasal cannula and oxygen concentrator in her room. The oxygen tubing was not labeled or dated. Observation and interview on 03/09/20 at 11:57 A.M. with Assistant Director of Nursing (ADON) #1 revealed per facility policy oxygen tubing should be labeled with the date it was initiated and changed every seven days to reduce the risk of contamination. ADON #1 verified Resident #9's oxygen tubing was not labeled or dated. 2. Review of Resident #161's medical record revealed an admission date of 02/20/20 with diagnoses including chronic respiratory failure with hypoxia, metabolic encephalopathy, hypertension, acute kidney failure, mood disorder, and major depressive disorder. Review of Resident #161's care plan dated 02/24/20 revealed the resident was at risk for ineffective airway exchange secondary to respiratory failure with interventions including oxygen to be administered as ordered. Review of Resident #161's MDS dated [DATE] revealed the resident was severely cognitively impaired. The resident was totally dependent on the assistance of two-persons for bed mobility, dressing, toileting, personal hygiene, transfers and bathing; and totally dependent on one-person for eating. Review of Resident #161's physician's order dated 03/03/20 revealed an order for oxygen administration via nasal cannula at two liters per minute for an oxygen saturation less than 90% and as needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366470 If continuation sheet Page 4 of 6 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 366470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054 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 0695 for hypoxia. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #161 on 03/09/20 at 11:27 A.M. revealed the resident had a nasal cannula and oxygen concentrator in his room. The oxygen tubing was not labeled or dated. Residents Affected - Few Observation and interview on 03/09/20 at 11:57 A.M. with Assistant Director of Nursing (ADON) #1 revealed per facility policy oxygen tubing should be labeled with the date it was initiated and changed every seven days to reduce the risk of contamination. ADON #1 verified Resident #9's oxygen tubing was not labeled or dated. Review of the facility policy, Department (Respiratory Therapy)-Prevention of Infection dated 10/17 revealed under Steps in Procedure, step number seven stated to change the oxygen cannula and tubing every seven days or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366470 If continuation sheet Page 5 of 6 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 366470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wesley Woods at New Albany 4588 Wesley Woods Blvd New Albany, OH 43054 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and medical record review the facility failed to ensure appropriate indication was in place for residents who received antipsychotic medication. This affected one (Resident #3) of four residents reviewed for unnecessary medications. The facility census was nine. Findings include: Review of the medical record for Resident #3 revealed an admission date of 12/18/19 with diagnoses of multiple fractures of the pelvis, dementia with behavioral disturbances, and major depressive disorder. Review of Resident #3's plan of care dated 12/19/19 revealed the resident may experience impaired cognition related to the diagnosis of dementia with long and short term memory loss. Resident #3 also had a care plan for the use of drugs having an altering effect on the mind characterized by hallucinations, delusions, involuntary movements, and tremors. Review of Resident #3's admission Medicare five day Minimum Data Set (MDS) 3.0 dated 12/24/19 revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating severe cognitive impairment. Resident #3 was noted to reject care and wander at times. Resident #3 was totally dependent on two staff members for all activities of daily living. Review of Resident #3's physician orders revealed an order dated 02/19/20 for Seroquel 25 milligrams (mg) (an antipsychotic used to treat schizophrenia, and bipolar disorder). Resident #3 was ordered to take half a tablet, 12.5 mg, two times a day for agitation. Review of Resident #3's behavior monitoring for December 2019, January 2020, February 2020, and March 2020, revealed one to two occurrences of the resident rejecting care per month. Interview on 03/11/20 at 12:00 P.M. with the Director of Nursing (DON) confirmed Resident #3 was receiving the antipsychotic medication Seroquel for agitation and not for one of the indicated diagnoses and the resident did not have a diagnosis of schizophrenia or bipolar disorder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366470 If continuation sheet Page 6 of 6