Inspection·February 6, 2025

F 0569 Level of Harm - Minimal harm or potential for actual harm 2) Review of the medical record for Resident #88 revealed the resident was admitted to the facility on [DATE] with diagnoses including insomnia, other seizures, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, acute posthemorrhagic anemia, fistula of vagina to large intestine, anemia, respiratory disorder and bipolar disorder. Resident #88 was discharged from the facility on 04/04/24. Residents Affected - Few Review of the Resident Funds Authorization, for Resident #88 dated 08/24/20, revealed the authorization was signed by Resident #88. The authorization was also witnessed by a non-employee. Review of a progress note for Resident #88 dated 04/04/24 at 8:00 A.M., revealed the resident was discharged home with her medications and personal belongings. Review of the discharge MDS assessment dated [DATE], revealed Resident #88 was cognitively intact. Review of a check dated 10/04/24, revealed the check was written out to Resident #88 on 10/04/24 for the amount of $458.00 dollars. Review of the Resident Funds Statement, dated 12/31/24, revealed Resident #88 had a balance of $458.00 dollars on 11/05/24 when the account was closed. Interview with the Administrator on 02/05/25 at 2:32 P.M., verified Resident #88 was discharged from the facility on 04/04/24 and Resident #88's funds were not conveyed to her within 30 days of Resident #88 discharged from the facility. 3) Review of the medical record for Resident #89 revealed the resident was admitted to the facility on [DATE]. Diagnoses including low back pain, major depressive disorder, vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, hypertension, hypothyroidism and generalized anxiety disorder. Resident #89 discharged from the facility on 11/30/24. Review of the quarterly MDS assessment dated [DATE], revealed Resident #89 was had impaired cognition. Review of a progress note for Resident #89 dated 11/30/24 at 7:45 A.M., revealed the resident's body was released to the funeral home. Resident #89's daughter and hospice were present. Review of the Resident Funds Statement, dated 12/31/24, revealed Resident #89 had a balance of $551.29 dollars on 12/18/24 when the account was closed. Review of the facility's Resident Account Information from 10/01/24 to 02/05/25, revealed Resident #89 did not have any checks to show the conveyance of Resident #89's funds in the amount of $551.29 dollars. There was also no documentation that Resident #89 or Resident #89's resident representative signed a resident funds authorization. Interview with the Administrator on 02/05/25 at 2:32 P.M., verified Resident #89 discharged from the facility on 11/30/24 and the facility did not have any proof of a check or Resident #89's funds being conveyed to their estate. Review of email correspondence from the Administrator on 02/06/25 at 8:44 A.M., verified the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 2 of 4 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 02/06/2025 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 0569 facility did not have a signed resident funds authorization to manage Resident #89's funds. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00161817. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 3 of 4 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 02/06/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure residents' advanced directives were updated and accurate in the medical record. This affected one Resident (#30) out of the two residents reviewed for advanced directives. The facility census was 18. Findings include: Review of the medical record for Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, hemiplegia, bipolar disorder, gastro-esophageal reflux disease (GERD), bipolar disorder, essential primary hypertension, hyperlipidemia, anxiety disorder, hypothyroidism, diabetes mellitus (DM), insomnia, schizoaffective disorder, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Review of a physician order dated 11/19/24 for Resident #30, revealed the resident was ordered to be Do Not Resuscitate Comfort Care (DNR-CC). Review of an DNR-CC paper form dated 11/19/24 and signed by the physician, revealed Resident #30 was marked as a DNR-CC. Review of the Minimum Data Set (MDS) assessment for Resident #30, dated 11/20/24, revealed the resident was cognitively intact. Review of Resident #30's paper chart at the nurse's desk, revealed a plain white paper with bold print indicating Resident #30 was a full code. Interview with the Director of Nursing (DON) on 02/03/25 at 12:06 P.M., verified Resident #30's advanced directives didn't match in the paper chart and the electronic medical record (EMR). The DON stated she was not aware of Resident #30 having had a change in his advanced directives. The DON stated Resident #30 should be listed as a DNR-CC. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 4 of 4