Health inspection·March 14, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete door closure mechanism cover and exposed wires. The Administrator also confirmed the exposed wired beside Resident #41's bed. This deficiency represents non-compliance investigated under Complaint Number OH00151988, Complaint Number OH00151983, Complaint Number OH00151974, Complaint Number OH00151928, Complaint Number OH00151922, and Complaint Number OH00151919. This deficiency represents ongoing non-compliance from the survey dated 03/04/24. 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 03/14/2024 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of a fall investigation, observations, staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident identified at high risk for falls and failed to conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #07 fell from the bed that was not in the lowest position and sustained a leg fracture requiring surgical intervention. This affected one (#07) of three residents reviewed for falls. The census was 72. Findings include: Review of Resident #07's medical record revealed an admission date of 07/20/20. Diagnoses included schizoaffective disorder, dementia, muscle wasting and atrophy, hypertension, anxiety disorder, and epilepsy. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #07 was significantly cognitively impaired with an brief interview for mental status (BIMS) score of zero out of 15 and was receiving Hospice services. Review of a care plan initiated 07/24/20 revealed Resident #07 was at risk for falls related to schizoaffective disorder, bipolar disorder, history of depression with psychotic symptoms, and shortness of breath. An intervention for Resident #07's bed in the lowest position was added to the care plan on 08/08/20. An intervention of educating staff on keeping bed in the lowest position when not providing Resident #07 care was added on 03/08/24. Resident #07 had activities of daily living (ADL) self-care performance deficit related to nicotine dependence, history of restlessness and/or agitation, shortness of breath, and verbal and or physical aggression. An intervention of mechanical aid of Hoyer (mechanical lift) for transfers with two staff participation and two staff participation for bed mobility to reposition up and turn in bed were added 07/24/20. Review of progress notes revealed Resident #07 had a history of falling from the bed. Resident #07 fell from his bed on 02/27/24, 03/04/24, and 03/08/24. Review of progress notes dated 03/08/24 revealed Resident #07 was heard yelling from his room and when the nurse entered the room, the resident was observed laying on the floor on his left side. Resident #07 complained of pain and was unable to move his left leg. Resident #07 was alert with confusion. The physician was notified, and orders were received to send Resident #07 to the emergency room (ER). Review of ER documentation dated 03/08/24 revealed Resident #07 was negative for fracture to the left leg. Review of progress notes dated 03/12/24 revealed when the nurse went to do wound treatment Resident #07 complained of pain when moved and touched. The nurse went with the physician to assess Resident #07 and an x-radiation (x-ray) to the left pelvis, left hip, left femur, left knee, left tibula, and left fibula were ordered. (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 03/14/2024 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 0689 Review of Resident #07's x-ray results dated 03/13/24 revealed a subacute left introchanteric femoral fracture with various malalignment. Level of Harm - Actual harm Residents Affected - Few Review of progress note dated 03/13/24 revealed Resident #07 was transferred to the ER due to x-ray findings of left femur fracture. Review of hospital documentation dated 03/13/24 revealed Resident #07 had a left introchanteric femoral fracture and was scheduled to have surgical repair on 03/14/24 with a left hip intramedullary nail. Review of Post-Fall Investigation revealed Resident #07 had an unwitnessed fall from bed on 03/08/24. A new intervention of staff to keep bed in the lowest position when providing care was added. State Tested Nursing Assistants (STNA's) were educated on 03/11/24. The Director of Nursing (DON), Regional Nurse #100, and Assisted Director of Nursing (ADON) #150 were interviewed on 03/14/24 at 11:30 A.M. ADON #150 stated that the agency nurse on duty 03/08/24 told her that Resident #07's bed was not in the lowest position when he was found on the floor. The DON and Regional Nurse #100 confirmed Resident #07's bed was not in the lowest position when he fell on [DATE]. The DON and Regional Nurse #100 confirmed Resident #07 sustained a leg fracture from a fall on 03/08/24. The DON and Regional Nurse #100 confirmed STNA's were educated on keeping Resident #07's bed in the lowest positions; however, no nurses were educated. There were no further interviews and/or further investigation as to who left the bed above the lowest position. Beds that go lower to the floor than Resident #07's bed were available in the facility. Resident #07 had fallen from bed on 02/27/24, 03/04/24, and 03/08/24. Observation of Resident #07's bed on 03/14/24 at 11:57 A.M. revealed bed controls were located at the foot of the bed. Review of the facility's Fall Response & Procedure dated 11/04/22 revealed it is the policy of this facility to ensure to the best of its ability the safety and well-being of residents who are at risk for falls and implement action steps post fall. A fall is considered a change in plane, an incident where if staff had not intervened i.e. lowering to the floor the resident would have fallen. If a resident is found down on the floor and was not witnessed, it will be investigated and treated as a fall. Nursing staff will initiate an investigation by observing the immediate environment for potential causes, obtain statement from resident as indicated, staff on duty, make note of position of residents, equipment, footwear, and evidence of action resident prior/at time of fall. Intervention will be added to guard against another fall of the same type. This deficiency represents non-compliance investigated under Complaint Number OH00152013. 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 03/14/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview, and review of facility policy, the facility failed to have an effective pest control program. This affected four (#05, #06, #07, and #08) out of four residents reviewed for pest control. The census was 72. Residents Affected - Some Findings include: Review of Resident #05's medical record revealed an admission date of 04/19/23. Diagnoses listed included major depressive disorder, paranoid schizophrenia, bipolar disorder, and psychotic substance abuse disorder. Review of Resident #06's medical record revealed an admission date of 01/20/23. Diagnoses listed included disorganized schizophrenia, metabolic encephalopathy, and alcohol abuse. Review of Resident #07's medical record revealed an admission date of 07/20/20. Diagnoses listed included schizoaffective disorder, dementia, muscle wasting and atrophy, hypertension, anxiety disorder, and epilepsy. Review of Resident #08's medical record revealed an admission date of 01/25/23. Diagnoses listed included Parkinson's disease, schizophrenia, dementia, anxiety disorder, and hypertension. Observation on 03/11/24 at 1:55 P.M. revealed gnats in Resident #05, #06, #07, and #08's room. Gnats were observed on ceiling, on resident divider curtains, and on bathroom walls. Observation and interview with the Director of Nursing (DON) on 03/11/24 at 2:42 P.M. confirmed the gnats in Resident #05, #06, #07, and #08's room. Observation on 03/12/24 at 2:42 P.M. revealed gnats in Resident #05, #06, #07, and #08's room. Gnats were observed on ceiling, on resident divider curtains, and on bathroom walls. Observation on 03/13/24 at 8:40 A.M. revealed gnats in Resident #05, #06, #07, and #08's room. Gnats were observed on Resident #07's blankets while he was in bed. Gnats were also observed on the ceiling, on resident divider curtains, and on bathroom walls. During an interview on 03/13/24 at 8:40 A.M. Regional Nurse #150 stated Resident #05, #06, #07, and #08's room was sprayed for gnats by the facility in 03/12/24. Regional Nurse #150 was unsure if a local pest control company had came to spray on 03/12/24. Observation and interview with the Administrator on 03/13/24 at 8:45 A.M. confirmed the gnats in Resident #05, #06, #07, and #08's room. The Administrator confirmed gnats on Resident #07's blankets while he was in bed. Review of the facility policy titled Pest Control dated revised May 2008 revealed the facility will maintain an effective pest control program to ensure that the building is kept free of insects and rodents. This deficiency represents non-compliance investigated under Complaint Number OH00151988, Complaint Number OH00151983, Complaint Number OH00151974, Complaint Number OH00151928, Complaint Number (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 03/14/2024 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 0925 OH00151922, and Complaint Number OH00151919. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 6 of 6