Health inspection·March 4, 2024

F 0584 Interview on 03/04/24 at 7:50 A.M. with Resident #59 revealed the facility did not have any hot water. Level of Harm - Minimal harm or potential for actual harm Interview on 03/04/24 at 7:52 A.M. with STNA #15 revealed the facility did not have hot water in all rooms on the secured unit. Residents Affected - Some Interview on 03/04/24 at 7:53 A.M. with STNA #18 revealed the facility did not have hot water in all rooms on the secured unit. Interview on 03/04/24 at 7:55 A.M. with Licensed Practical Nurse (LPN) #802 revealed the facility did not have hot water in all rooms on the secured unit. Observation of Maintenance Director #800 taking water temperatures on the secured unit on 03/04/24 at 9:07 A.M. revealed the water temperature was 100 degrees Fahrenheit in Resident #44, #48, #49, #53, #58, #62, #63 and #66's rooms, the water temperature was 95 degrees Fahrenheit in Resident #57's room and in the 500-hallway shower room, and the water temperature was 98 degrees Fahrenheit in Resident #60, Resident #71, and Resident #72's rooms. Interview with Maintenance Director #800 on 03/04/24 at 9:07 A.M. verified all the rooms and the shower room on the secured unit were serviced by the same water heater and all the water temperatures on the secured unit did not get above 100 degrees Fahrenheit due to the water heater not working properly. Interview on 03/04/24 at 9:30 A.M. with Resident #60 revealed the facility's water did not have hot and the water in the shower was cold. Interview with the Administrator and Maintenance Director #800 on 03/04/24 at 3:11 P.M. revealed the hot water heater on the secured unit malfunctioned on 01/18/24 and the facility had received multiple estimates to replace the water heater, but a new water heater was not purchased by the facility until 03/01/24. Maintenance Director #800 confirmed the water heater purchased on 03/01/24 had not been installed at the facility and the facility had not had hot water above 100 degrees Fahrenheit on the secured unit since 01/18/24. The Administrator and Maintenance Director #800 stated the facility did not have any documentation regarding routine maintenance on the water heater. The Administrator stated the facility only had water temperatures documentation on 02/15/24, 02/28/24 and 02/28/24 for the past 90 days. Review of the facility's water temperature policy dated 01/01/18 revealed the facility will maintain water temperatures within an acceptable range. This deficiency represents non-compliance investigated under Complaint Number OH00151569. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 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 365022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Nursing and Rehabilitation 1301 North Monroe Drive Xenia, OH 45385 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident and staff interviews and review of facility policy, the facility failed to maintain essential equipment to provide hot water to the residents. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72. Residents Affected - Some Finding include: Review of the plumbing contractor proposal dated 01/18/24 revealed the facility was quoted $15,243 to replace a water heater. Review of a second plumbing contractor proposal dated 01/24/24 revealed the facility was quoted $12,500 to replace a water heater. Review of facility's water temperature documentation log dated 02/15/24 revealed the water temperature on the secured unit ranged from 75 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's water temperature documentation log dated 02/28/24 revealed the water temperature on the secured unit ranged from 80 degrees Fahrenheit to 98 degrees Fahrenheit. Review of facility's water temperature documentation log dated 02/28/24 revealed the water temperature on the secured unit ranged from 85 degrees Fahrenheit to 96 degrees Fahrenheit. Review of the receipt for a water heater dated 03/01/24 revealed a water heater was purchased for $6302.08 on 03/01/24. Review of the facility's water temperature policy dated 01/01/18 revealed the facility will maintain water temperatures within an acceptable range. Interview on 03/04/24 at 7:45 A.M. with Registered Nurse (RN) #803 revealed there was no hot water on the secured behavioral unit. Interview on 03/04/24 at 7:46 A.M. with State Tested Nurse Aide (STNA) #804 revealed there was no hot water on the secured unit. Interview on 03/04/24 at 7:50 A.M. with Resident #48 revealed the facility did not have any hot water. Interview on 03/04/24 at 7:50 A.M. with Resident #59 revealed the facility did not have any hot water. Interview on 03/04/24 at 7:52 A.M. with STNA #15 revealed the facility did not have hot water in all rooms on the secured unit. Interview on 03/04/24 at 7:55 A.M. with Licensed Practical Nurse (LPN) #802 revealed the facility did not have hot water in all rooms on the secured unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 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 365022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Nursing and Rehabilitation 1301 North Monroe Drive Xenia, OH 45385 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 0908 Level of Harm - Minimal harm or potential for actual harm Observation of Maintenance Director #800 taking water temperatures on the secured unit on 03/04/24 at 9:07 A.M. revealed the water temperature was 100 degrees Fahrenheit in Resident #44, #48, #49, #53, #58, #62, #63 and #66's rooms, the water temperature was 95 degrees Fahrenheit in Resident #57's room and in the 500-hallway shower room, and the water temperature was 98 degrees Fahrenheit in Resident #60, Resident #71, and Resident #72's rooms. Residents Affected - Some Interview with Maintenance Director #800 on 03/04/24 at 9:07 A.M. verified all rooms and the shower room on the secured unit were serviced by the same water heater and all the water temperatures on the secured unit did not get above 100 degrees Fahrenheit due to the water heater not working properly. Interview on 03/04/24 at 9:30 A.M. with Resident #60 revealed the facility's water in the shower was cold. Interview with the Administrator and Maintenance Director #800 on 03/04/24 at 3:11 P.M. revealed the hot water heater on the secured unit malfunctioned on 01/18/24 and the facility had received multiple estimates to replace the water heater, but a new water heater was not purchased by the facility until 03/01/24. Maintenance Director #800 confirmed the water heater purchased on 03/01/24 had not been installed at the facility and the facility had not had hot water above 100 degrees Fahrenheit on the secured unit since 01/18/24. The Administrator and Maintenance Director #800 stated the facility did not have any documentation regarding routine maintenance on the water heater. The Administrator stated the facility only had documentation of water temperatures on 02/15/24, 02/28/24 and 02/28/24, for the past 90 days. This deficiency represents non-compliance investigated under Complaint Number OH00151569. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 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 365022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Nursing and Rehabilitation 1301 North Monroe Drive Xenia, OH 45385 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, record review and staff interview, the facility failed to ensure an egress door's push bar was maintained and working properly on the secured behavioral unit. This affected 33 residents (#41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73) out of 72 residents at the facility. The facility census was 72. Findings include: Observation of the secured unit's interior egress right side door on 03/04/24 at 7:47 A.M. revealed the door had a sign which indicated Push until alarm sounds - Door can be opened in 15 seconds. The door did not have a push bar to exit the unit to the main common area of the facility, but the door was noted to have two gold pieces attached to the right door where the push bar had previously been attached to the door. Further observation of secured unit revealed State Tested Nurse Aide (STNA) #801 was pulling the metal lip open on the left door to exit the unit instead of pressing on the right door that had the missing push bar. Interview with STNA #801 on 03/04/24 at 7:47 A.M. verified the right door's push bar was missing from the inside of the interior secured unit egress door. STNA #801 stated she had to pull apart the doors by pulling the metal lip of the left door. STNA #801 reported the door could not be opened by pushing on the door because the door's push bar to exit the unit was missing. Interview with STNA #15 on 03/04/24 at 7:52 A.M. verified the door's push bar used to exit the secured unit had broken and was taken off the door. STNA #15 stated she did not know when the push bar was broken. Interview with STNA #18 on 03/04/24 at 7:53 A.M. verified the door's push bar used to exit the secured unit had broken and was taken off the door. STNA #18 stated she did not know when the door push bar was broken but stated it had been a long time. Observation on 03/04/24 at 7:55 A.M. revealed LPN #802 entered the code on the keypad and opened the interior door by having to pull the metal lip open on the left door to exit the unit instead of pressing on the door on the right side that had the missing door push bar. The door's alarm function was still operational. Interview with Licensed Practical Nurse (LPN) #802 on 03/04/24 at 7:55 A.M. verified the door's push bar used to exit the secured unit had broken and was taken off the door. LPN #802 stated she did not know when the door push bar was broken. Interview with Maintenance Director #800 on 03/04/24 at 9:07 A.M. verified the door's push bar used to exit the secured unit had broken and was taken off the door. Maintenance Director #800 stated that the Administrator was going to try to find someone that could weld the door's push bar piece back together. Interview with the Administrator on 03/04/24 at 3:11 P.M. revealed the interior secured unit egress door's push bar broke and was removed from the door approximately two weeks ago. The Administrator stated that the door's push bar had not been on the door in two weeks and that the facility was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 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 365022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Atrium Nursing and Rehabilitation 1301 North Monroe Drive Xenia, OH 45385 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 0921 Level of Harm - Minimal harm or potential for actual harm attempting to find someone to weld the broken piece or buying a new push bar. The Administrator confirmed the facility was not able to produce any documentation that a door push bar was purchased or any inquiries from companies that could replace or fix the push bar. This deficiency represents non-compliance investigated under Complaint Number OH00151094. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 6 of 6