Health inspection·June 26, 2025

F 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the Administrator on 06/25/25 at 4:30 P.M. verified Resident #8's resident funds account statement from 04/01/25 to 06/05/25 showed a total of $380.00 in debits from 04/01/25 to 06/05/25 for personal needs items and the facility's receipts showed a total of $280.00 was signed out of the resident funds account by Resident #8 from 04/01/25 to 06/05/25. The Administrator confirmed Resident #8's account statement did not match the receipts for debits because the facility withdrew the money from Resident #8's resident funds account when the facility received Resident #8's monthly deposited funds in the account. The Administrator reported the facility put the withdrawn funds in an individual petty cash envelope that was kept by the facility in a petty cash box until Resident #8 signed out the money on the receipt ledger. The Administrator stated the facility had $100.00 in a petty cash envelope for Resident #8. The Administrator verified the $100.00 dollars held by the facility in the petty cash envelope was not an interest bearing account. Event ID: Facility ID: 365022 If continuation sheet Page 2 of 17 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 06/26/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, staff interview, and review of a facility census document, the facility failed to ensure adequate hot water was supplied to a common shower room and resident rooms. This affected six (#8, #9, #11, #12, #13, and #19) of 19 residents that resided at the facility. The facility census was 19. Findings include: Observation of Maintenance Aide (MA) #244 taking the water temperatures on 06/22/25 beginning at 10:19 A.M. revealed the hot water temperature in the 500 Hall shower room was 97.8 degrees Fahrenheit (F), the hot water temperature in Resident #8's room was 95.6 degrees F, the hot water temperature in Resident #9's room was 93.1 degrees F, the hot water temperature in Resident #11's room was 88.8 degrees F, and the hot water temperature in Resident #12's room was 88.9 degrees F. Interview with MA #244 on 06/22/25 at 10:19 A.M., during observation of the hot water temperatures, verified the hot water temperature in the 500 Hall shower room, Resident #8, Resident #9, Resident #11, and Resident #12's rooms were not supplying an adequate hot water source. Review of the facility census dated 06/22/25 revealed Resident #8, Resident #9, Resident #11, Resident #12, Resident #13, and Resident #19 all resided on the 500 Hall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 3 of 17 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 06/26/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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, staff interview, and review of the Resident Assessment Instrument 3.0 manual, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and submitted per the Centers of Medicare and Medicaid Services requirements. This affected six (#4, #8, #13, #16, #17, and #18) of 19 residents reviewed for resident assessments. The facility census was 19. Residents Affected - Some Findings included: 1. Review of the medical record for Resident #4 revealed an admission on [DATE] with diagnoses including but not limited to muscular dystrophy, heart failure, anxiety disorder, hypertension, and contractures of the hand. Review of the comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/20/25 for Resident #4 revealed the resident had intact cognition. Resident #4 was coded as dependent for eating, toileting, bed mobility, and transfers. The assessment was completed and locked on 06/02/25 and submitted to the Centers of Medicare and Medicaid (CMS) on 06/04/25. 2. Medical record review for Resident #8 revealed an admission date of 10/31/22 with diagnoses including but not limited to schizoaffective disorder, psychotic disorder with delusions, anxiety, depression, hypertension, history of non-suicidal self-harm, chronic pain, and noncompliance with medication. Review of the quarterly MDS assessment with an ARD of 04/21/25 for Resident #8 revealed the resident had severely impaired cognition. Resident #8 was coded with hallucinations and delusions, verbal behaviors directed at others, rejection of care, and behaviors not directed at others. Resident #8 required assistance for eating and supervision for toileting bed mobility and transfers. The assessment was completed and locked on 06/02/25 and submitted on 06/04/25. 3. Medical record review for Resident #18 revealed an admission date of 01/18/24 with diagnoses including but not limited to paroxysmal atrial fibrillation, mild neurocognitive disorder without behaviors, cerebral infarction without residual, hypertension, cardiomyopathy, late syphilis latent, and myocardial infarction. Review of the quarterly MDS assessment with an ARD of 04/16/25 for Resident #18 revealed the resident had intact cognition. Resident #18 was coded with rejection of care four to six days in the assessment period. The assessment was completed on 06/02/25 and submitted on 06/04/25. 4. Medical record review for Resident #13 revealed an admission date of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease, emphysema, acute and chronic respiratory failure, anxiety disorder, insomnia, major depression, schizoaffective disorder bipolar type, alcohol dependence in remission, hypertension, hallucinations, and anemia. Review of the quarterly MDS assessment dated [DATE] for Resident #13 revealed the resident had intact cognition. Resident #13 required set up for eating, was dependent for toileting, and required moderate assistance for bed mobility. The assessment was completed on 06/02/25 and submitted on 06/04/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 4 of 17 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 06/26/2025 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 0640 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 06/25/25 at 1:39 P.M. with MDS Nurse/Licensed Practical Nurse (LPN) #270 confirmed the MDS assessments for Resident #4, Resident #8, Resident #13, and Resident #18 were completed and submitted late. Interview on 06/26/25 at 9:26 A.M. with Corporate Registered Nurse (RN) #505 stated the facility's MDS nurse quit during the transition of owners and resident assessments were not completed according to the required time frame. RN #505 verified the assessments for Resident #4, Resident #8, Resident #13, and Resident #18 were completed and submitted late. 5. Review of the medical record for Resident #16 revealed an admission date of 11/09/22 with diagnoses of epilepsy with status epilepticus, essential hypertension, and cerebral infarction without residual deficits. Review of the MDS assessment with an ARD of 04/03/25 revealed Resident #16 was assessed with severe cognitive impairment. Further review of the MDS assessment revealed the assessment was completed on 04/28/25. 6. Review of the medical record for Resident #17 revealed an admission date of 11/27/23 with diagnoses of schizoaffective disorder bipolar type, type II diabetes mellitus without complications, hemiplegia affecting the right dominant side, and anxiety. Review of the MDS assessment with an ARD of 05/08/25 revealed Resident #17 was cognitively intact. Further review of the MDS assessment revealed the assessment was completed on 06/02/25. Interview on 06/25/25 at 1:39 P.M. with MDS Nurse/LPN #270 confirmed Resident #16's MDS assessment with an ARD of 04/03/25 was completed late on 04/28/25 and Resident #17's MDS assessment with an ARD of 05/08/25 was completed late on 06/02/25. MDS Nurse/LPN #270 confirmed the facility was late on a lot of resident MDS assessments and the facility was trying to catch up. Review of the Centers of Medicare and Medicaid Services Resident Assessment Instrument 3.0, dated October 2024, revealed admission assessments should be completed and submitted within fourteen calendar days from admission and quarterly assessments should be completed and submitted within fourteen days of the assessment reference date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 5 of 17 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 06/26/2025 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 0641 Ensure each resident receives an accurate assessment. 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, observations, review of shower schedules, review of shower sheets, resident and staff interview, and review of the Resident Assessment Instrument manual, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was accurate. This affected one (#13) of five residents reviewed for accurate MDS assessments. The facility censes was 19. Residents Affected - Few Findings included: Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hallucinations and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had intact cognition. Resident #13 required set up for eating, was dependent for toileting, and required moderate assistance for bed mobility. Resident #13 was not coded with any rejections of care during the assessment period. Review of the plan of care for Resident #13 dated 11/24/21 revealed the resident was resistive to care and refused activities of daily living assistance from staff. Resident #13 will refuse showers and bed baths at times. Interventions include allow to allow the resident to make choices, and if the resident refuses care reapproach at a later time. Review of the undated facility shower schedule in a binder at the nurses station for Resident #13 revealed a shower or bath was to be provided on Wednesday and Saturday on the 7:00 P.M. to 7:00 A.M. shift. Review of the facility shower sheets dated 05/03/25 and 05/07/25 for Resident #13 revealed the resident refused bathing and bed linen change. Further review of the documents revealed staff had reported the refusal to the nurse. The shower sheets for 05/03/25 and 05/07/25 both contained a nurses signature at the bottom of the document. Observation and interview on 06/23/25 at 2:07 P.M. with Resident #13 stated he takes a bath every Friday. Interview on 06/24/25 at 3:36 P.M. with Certified Nurse Aide (CNA) #224 stated Resident #13 will not allow facility staff to bathe him and he will wait for the hospice staff to complete a bath when they come in. CNA #224 stated the facility used shower sheets and if the resident refused that information was put on the sheet and given to the facility nurse to sign. Interview 06/26/25 at 12:46 P.M. with MDS Nurse/Licensed Practical Nurse (LPN) #270 verified he was unaware the facility used shower sheets and Resident #13 refused care during the assessment period. LPN #270 verified the MDS assessment completed on 05/08/25 was inaccurate and should have included the resident's refusals of care. Review of the Resident Assessment Instrument Manual, dated October 2024, revealed in chapter three on page E-15, staff should review the medical record, interview staff across all shifts during the seven day look back period, and code section E (Behavior) of the MDS assessment with the identified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 6 of 17 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 06/26/2025 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 0641 findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 7 of 17 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 06/26/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, staff interview, and review of a facility policy, the facility failed to ensure wound care on a resident's surgical wound was completed based on the physician's order. This affected one (#10) of one resident reviewed for surgical wounds. The facility census was 19. Residents Affected - Few Findings include: Review of Resident #10's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, unspecified protein calorie malnutrition, chronic multifocal osteomyelitis, asthma, anxiety disorder, frostbite with tissue necrosis of the left foot, alcohol abuse, peripheral vascular disease, and gangrene. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and the resident required moderate assistance with showers. Resident #10 was independent with eating, rolling left and right, sitting to lying, and lying to sitting and required set up assistance with oral hygiene, upper body dressing, and sitting to standing. Resident #10 required supervision with toileting, lower body dressing, putting on and taking off footwear, personal hygiene, chair transfers, and toilet transfers and Resident #10 had a surgical wound. Review of Resident #10's skin breakdown care plan dated 05/16/25 revealed the resident was at risk for skin breakdown. Interventions included administer medications as ordered, apply lotion to dry skin as needed, assist with turning and repositioning, and a pressure redistribution mattress to the bed. Review of Resident #10's non-compliance care plan dated 06/02/25 revealed Resident #10 refused wound treatments at times. Interventions included to document educational attempts made with the resident, notify the physician of non-compliance, and explain all procedures before starting them. Review of Resident #10's wound care progress note dated 05/13/25 revealed the resident was seen by Wound Care Nurse Practitioner (WCNP) #500 for a non-healing surgical ulceration of the left midline stump that was 1.5 centimeter (cm) in length by 2.5 cm in width by 0.1 cm in depth. The wound was listed as improving. A new treatment order was given to clean with wound cleanser and pat dry, apply tetracyte to the wound be, then collagen and then oil emulsion, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident #10's wound care progress note dated 05/20/25 revealed the resident was seen by WCNP #500 with a non-healing surgical ulceration of the left midline stump that was 1.8 cm in length by 1.3 cm in width by 0.1 cm in depth. The wound was listed as improving. The treatment order was to clean with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident #10's wound care progress note dated 05/27/25 revealed the resident was seen by WCNP #500 with a non-healing surgical ulceration of the left midline stump that was 2.0 cm in length by 3.0 cm in width by 0.1 cm in depth. The wound was listed as increasing in size. A new treatment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 8 of 17 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 06/26/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order was given to clean with wound cleanser and pat dry, apply tetracyte to the wound bed and medical honey, cover with an abdominal pad, and wrap with rolled gauze and tape to secure three times a week and as needed. The note was signed by WCNP #500. Review of Resident 108's physician order dated 04/17/25, and discontinued on 05/28/25, revealed the resident was ordered a treatment to the left foot and stump. Resident #10's wound was to be cleansed with wound cleanser and pat dry, apply tetracyte and oil emulsion to the wound, cover with an abdominal pad and secure with kerlix, and an ace bandage three times a week and as needed on Tuesday, Thursday, and Saturday for wound healing. Review of Resident #10's treatment administration record (TAR) from 05/13/25 to 05/27/25 revealed Resident #10's wound to his left foot and stump was cleansed with facility wound cleanser and patted dry, tetracyte and oil emulsion were applied to the wound and the wound was covered with an abdominal pad and secured with kerlix and an ace bandage on 05/13/25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, and 05/27/25. Interview with Assistant Director of Nursing (ADON) #236 on 06/25/25 at 7:45 A.M. verified WCNP #500 ordered Resident #10's wound to his left foot and stump to be cleaned with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad and wrap with rolled gauze and tape to secure three times a week and as needed from 05/13/25 to 05/27/25. ADON #236 confirmed Resident #10's wound to his left foot and stump was cleansed with facility wound cleanser and patted dry, tetracyte and oil emulsion were applied to the wound, and the wound was covered with an abdominal pad and secured with kerlix and an ace bandage on 05/13/25, 05/15/25, 05/17/25, 05/20/25, 05/22/25, 05/24/25, and 05/27/25. ADON #236 confirmed Resident #10 did not receive collagen to the left foot surgical ulcer wound as ordered by WCNP #500 from 05/13/25 to 05/27/25. Telephone interview on 06/26/25 at 9:05 A.M. with WCNP #500 revealed Resident #10 had a surgical ulcer to the left foot that was reoccurring due to Resident #10's non-compliance with using the left foot and stump for ambulation and picking at the wound. WCNP #500 verified that she ordered Resident #10's left foot wound to be cleaned with wound cleanser and pat dry, apply tetracyte to the wound bed then collagen and then oil emulsion, cover with an abdominal pad and wrap with rolled gauze and tape to secure three times a week and as needed from 05/13/25 to 05/27/25. WCNP #500 stated she was not aware that collagen was not being applied to the wound as ordered from 05/13/25 to 05/27/25 but WCNP #500 reported the absence of collagen would not impact the wound healing. Review of the facility's wound care policy, dated October 2010, revealed the facility will verify that there was a physician order for the wound care procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 9 of 17 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 06/26/2025 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 0687 Provide appropriate foot care. 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 and resident interview, and policy review, the facility failed to ensure application of prescribed foot care treatments were completed as ordered. This affected one (#18) of one residents reviewed for prescribed foot treatments. This facility census was 19. Residents Affected - Few Findings included: Medical record review for Resident #18 revealed an admission of 01/18/24 with diagnoses including but not limited to paroxysmal atrial fibrillation, mild neurocognitive disorder without behaviors, cerebral infarction without residual residual, hypertension, late syphilis latent, and myocardial infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #18 revealed the resident had an intact cognition. Resident #18 was coded with behaviors including rejection of care four to six days in the assessment period. Resident #18 was assessed to require supervision for eating, toileting, personal hygiene, bed mobility, and transfers. Resident #18 had no skin issues coded. Review of the current plan of care for Resident #18 revealed the resident was at risk for skin breakdown related to mild neurocognitive disorder and decreased mobility. Interventions include to administer medication as ordered, apply lotion to dry skin as needed, assist the resident to the bathroom as needed, assist the resident with turning and repositioning, and a pressure redistribution mattress to bed. Review of the current physician orders for Resident #18 revealed an order dated 06/03/25 for vitamin A&D ointment (a skin protectant) to bilateral feet every night for dry skin and an order for Eucerin advanced repair external cream (emollient) with instructions to apply to bilateral feet topically one time a day for severe xerosis (rough dry skin with scales or small cracks). Review of the facility's electronic health record for Resident #18 revealed no evaluation for the purpose of the resident self-administering prescribed medication. Review of the June 2025 treatment administration record (TAR) for Resident #18 revealed the order for vitamin A&D ointment to the bilateral feet at bedtime for dry skin revealed facility staff signed the treatment off as completed without refusals every day. Review of the medication administration record (MAR) for Resident #18 revealed the order Eucerin advanced repair external cream (emollient) to apply to bilateral feet topically one time a day for severe xerosis revealed facility staff signed the application as completed with one refusal on 06/26/25. Review of the progress note for Resident #18 dated 06/03/25 at 1:53 P.M. revealed Resident #18 was seen by the physician with new treatment orders given to apply vitamin A&D ointment to the resident's bilateral feet at bedtime. Resident #18 was aware of new orders. Observation and interview on 06/23/25 at 1:23 P.M. with Resident #18 revealed the resident was in bed with feet visible. Resident #18's bilateral feet and ankles had large areas of dry white flaky (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 10 of 17 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 06/26/2025 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 0687 skin. Resident #18 stated the physician had ordered a lotion but it was not always available. Level of Harm - Minimal harm or potential for actual harm Interview on 06/25/25 at 10:51 A.M. with Registered Nurse (RN) #239 stated she offered the Eucerin cream that morning to Resident #18 and the resident told her he had it in the room and would apply it. Residents Affected - Few Interview on 06/25/25 at 10:55 A.M. with Resident #18 verified he had a tube of lotion that he would apply. When asked about the lotion the resident revealed a tube of vitamin A&D ointment, and stated it was the only tube he had in the room. Observation of the resident's right foot during the interview revealed it was very dry and unchanged from the previous observation. Interview on 06/25/25 at 10:58 A.M. with RN #239 verified she did not have any Eucerin cream in her cart for Resident #18 and would order it from the pharmacy. Interview on 06/25/25 at 11:02 A.M. with facility Pharmacy [NAME] Representative #502 stated the pharmacy received an order on 01/14/25 and sent a one time supply for five days of Eucerin cream for Resident #18. Pharmacy [NAME] Representative #502 verified no other refills were requested or sent for Resident #18. Interview on 06/25/25 at 11:16 A.M. with RN #239 verified the facility conducted an assessment for any self-administration of prescriptions after asking Assistant Director of Nursing (ADON) #236 sitting at the nursing station with the RN. Interview on 06/25/25 at 11:19 A.M. with ADON #236 verified no self-administration evaluation was conducted for Resident #18. Interview on 06/25/25 at 11:26 A.M. with RN #239 stated she worked last Saturday and Sunday and used the tube of cream in Resident #18's room, signing off the medical record for the Eucerin cream. RN #18 confirmed the tube of vitamin A&D ointment in the resident's room was used for the treatment and not the Eucerin cream. RN #239 stated she thought it was same thing only named differently. Review of the facility policy titled, Administering Topical Medication, dated 10/2010, revealed staff will check the label on the medication and confirm the medication name and dose with the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 11 of 17 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 06/26/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, staff interview, review of a facility census document, medical record review, review of water temperature logs, and facility policy review, the facility failed to ensure hot water temperatures were maintained in a safe manner. This affected 13 (#1, #2, #3, #4, #5, #6, #7, #10, #14, #15, #16, #17, and #18) of 19 residents that resided at the facility. The facility census was 19. Findings include: Observation of Maintenance Aide (MA) #244 taking the water temperatures on 06/22/25 at 10:19 A.M. revealed the hot water temperature in the 600 shower room was 136.4 degrees Fahrenheit (F), the hot water temperature in Resident #1 and Resident #10's room was 134.7 degrees F, the hot water temperature in Resident #2's room was 135.9 degrees F, the hot water temperature in Resident #3's room was 134.6 degrees F, the hot water temperature in Resident #4's room was 136.6 degrees F, the hot water temperature in Resident #5's room was 134.1 degrees F, the hot water temperature in Resident #6's room was 133.4 degrees F, the hot water temperature in Resident #7's room was 136.5 degrees F, the hot water temperature in Resident #14's room was 126.4 degrees F, the hot water temperature in Resident #15's room was 136.2 degrees F, the hot water temperature in Resident #16's room was 134.5 degrees F, and the hot water temperature in Resident #18's room was 133.0 degrees F. Interview with MA #244 on 06/22/25 at 10:19 A.M., during observation of the water temperatures, verified the hot water temperature in the 600 shower room, Resident #1 and Resident #10, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #14, Resident #15, and Resident #16's rooms were all elevated and should not be that hot. Review of weekly water temperatures obtained between 02/13/25 and 06/19/25 revealed all water temperatures were below 120 degrees F. Further review of water temperatures obtained on the 600 Hall on 06/19/25 revealed the temperatures ranged between 119 degrees and 120 degrees F. Review of the facility census dated 06/22/25 revealed Resident #1, Resident #5, Resident #6, Resident #10, and Resident #14 resided on the 600 Hall. Review of the medical records for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10, Resident #14, Resident #15, Resident #16, Resident #17, and Resident #18 revealed no documented evidence of burns or incidents related to hot water exposure. Review of the facility's safety of water temperatures policy, dated December 2009, revealed tap water in the facility shall be kept within a temperature range to prevent the scalding of residents. Water heaters that service resident rooms, bathrooms, common areas and tub and shower areas shall be set to temperatures of no more than 120 degrees F or the maximum allowable temperature per state regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 12 of 17 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 06/26/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility provided medication administration time verification document, staff interview, and review of a facility policy, the facility failed to ensure medications were administered within prescribed timeframes. This affected one (#7) of one resident reviewed for pain medication administration. The facility census was 19. Findings include: Review of the medical record for Resident #7 revealed an admission date of 12/28/18 with diagnoses of quadriplegia, morbid (severe) obesity due to excess calories, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, required supervision assistance with eating, required partial assistance with oral hygiene, required substantial assistance with bed mobility, and was dependent on staff assistance with toileting hygiene, bathing, dressing, personal hygiene, transfers, and wheelchair mobility. Review of the care plan for Resident #7 with a revision date of 11/02/23 revealed the resident was at risk for pain related to decreased mobility and depression with intervention of administer medication as ordered. Review of Resident #7's physician orders revealed an order dated 04/01/25 for the narcotic pain medication hydrocodone-acetaminophen 5-325 milligrams (mg) tablet with instructions to give a 0.5 tablet by mouth two times a day for pain at 9:00 A.M. and 9:00 P.M. Review of the administration times for Resident #7's hydrocodone-acetaminophen 5-325 mg revealed on 06/15/25 the administration time was 10:09 A.M., on 06/16/25 the administration time was 10:19 A.M., on 06/20/25 the administration time was 1:59 P.M., on 06/23/25 the administration time was 10:39 A.M., and on 06/25/25 the administration time was 10:21 A.M. Interview on 06/26/25 at 11:46 A.M. with the Administrator confirmed Resident #7 had an order to receive hydrocodone-acetaminophen 5-325 mg, 0.5 tablet at 9:00 A.M. and 9:00 P.M. daily. The Administrator also confirmed Resident #7 did not receive the medication until 10:09 A.M. on 06/15/25, 10:19 A.M. on 06/16/25, 1:59 P.M. on 06/20/25, 10:39 A.M. on 06/23/25, and 10:21 A.M. on 06/25/25. The Administrator confirmed Resident #7 received this medication late on 06/15/25, 06/16/25, 06/20/25, 06/23/25, and 06/25/25. Review of the facility policy for administering medications, dated April 2019, revealed medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 13 of 17 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 06/26/2025 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were reviewed and addressed in a timely manner. This affected one (#9) of five residents reviewed for unnecessary medications. The facility census was 19. Findings include: Review of Resident #9's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting the right non-dominant side, cerebral infarction, insomnia, schizoaffective disorder bipolar type, generalized anxiety disorder, conversion disorder with seizures or convulsions, bipolar disorder, and Behcet's disease. Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #9's physician order dated 12/16/24 revealed the resident was ordered the narcotic pain medication tramadol 50 milligrams (mg) every eight hours as needed for pain. Review of Resident #9's pharmacy recommendation dated 04/11/25 revealed the physician should evaluate Resident #9's as needed tramadol for discontinuation. Resident #9's physician disagreed with the recommendation because Resident #9 used the medication as needed. The pharmacy recommendation was signed by the physician on 06/17/25. Interview with the Administrator on 06/24/25 at 3:16 P.M. verified Resident #9's pharmacy recommendation dated 04/11/25 was not addressed by the physician until 06/17/25. Review of the facility's medication regimen review policy, dated May 2019, revealed pharmacy recommendations will be completed within a 30 day timeframe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 14 of 17 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 06/26/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, hospice staff interviews, hospice contract review, and facility policy review, the facility failed to ensure collaboration with hospice providers for resident care. This affected two (#1 and #13) of two residents reviewed for hospice care. The facility census was 19. Findings include: 1. Medical record review for Resident #13 revealed an admission dated of 11/23/21 with diagnoses that included chronic obstructive pulmonary disease (COPD), emphysema, acute and chronic respiratory failure, anxiety disorder, schizoaffective disorder bipolar type, hypertension, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 revealed the resident had an intact cognition. Resident #13 required set up for eating, was dependent for toileting, required moderate assistance for bed mobility, and transfers were not applicable. Resident #13 was coded as receiving hospice services during the look back period. Review of the facility plan of care for Resident #13 dated 07/26/24, and revised on 08/13/24, revealed the resident had a terminal prognosis and received hospice services related to COPD. Interventions include medication administration, consultation with the hospice team to ensure needs are met, encourage expression of feelings, hospice to assist with social services, physician, certified nurse aide (CNA), nurse, and pastoral care as needed, involve family, significant other and/or responsible party per resident choice, staff to provided one-on-one as needed, and hospice contact information. Review of the plan of care for Resident #13 dated 11/23/21, and revised on 07/18/24, revealed the resident had an activity of daily living (ADLs) deficit related to decreased mobility and memory impairment. Interventions included the resident needed one person with extensive assistance for bathing. Review of the hospice initial interdisciplinary plan of care dated 07/25/24 for Resident #13 revealed weekly staff frequency to include nurse, social worker, and chaplain. The hospice aide and volunteer schedule were documented as per the plan of care and lacked frequency. Review of the active physicians' orders for Resident #13 revealed an order dated 07/25/24 for admission to a hospice agency with primary diagnosis of COPD. Review of the hospice agency visit description log for Resident #13 revealed a CNA visited the resident on 03/27/25, 04/10/25, 04/17/25, 05/02/25, 05/15/25, 05/30/25, 06/06/25, and 06/13/25. Further review revealed a registered nurse (RN) visited on 04/18/25, 05/30/25, and 06/17/25. No other documentation was present in the hospice binder for Resident #13. Review of the multidisciplinary conference dated 05/07/25 for Resident #13 revealed the resident, a family member, nursing, social services, and business office staff were present for the meeting. Observation and interview on 06/23/25 at 2:07 P.M. with Resident #13 revealed the resident's finger nails were long, jagged and have dark soft material under all nails. Resident #13 stated he received a bath on Friday and did not know where the aide was from, but she did not work for the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 15 of 17 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 06/26/2025 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/24/25 at 3:00 P.M. with Hospice Director of Nursing (DON) #500 verified the hospice agency does not leave any documentation for the facility after each visit and if they would like a copy they can call the office. Interview on 06/24/25 at 3:07 P.M. with the facility Director of Nursing (DON) #278 verified the hospice provider has not provided the facility with any progress notes from visits documented on the visit description log in the hospice binder for Resident #13. Interview on 06/24/25 at 3:12 P.M. with Hospice Social Worker (HSW) #501 stated she just started with the company and stated the hospice staff will talk to the nurse on duty after the visits to collaborate on visit details. HSW #501 stated they do not have a specific staff member at the facility and staff will just talk with the nurse on duty at the time of the visit. Interview on 06/24/25 at 03:36 P.M. with CNA #224 stated the hospice staff do not follow a schedule for Resident #13 and will randomly show up for a bath. Interview on 06/24/25 at 3:46 P.M. with Registered Nursing (RN) #265 stated sometimes she will ask the hospice staff when she sees them, but they will come in and leave without saying a word to her at times. RN #265 stated the hospice aid was here last Friday and gave Resident #13 a bed bath. RN #265 verified the aide did not sign the hospice documentation that she completed any care. RN # 265 verified the hospice binder did not have any documentation for visits for Resident #13. Interview on 06/26/25 at 1:19 P.M. with Business Office Staff Member #275 stated she conducted the care conferences and had not had the hospice staff for Resident #13 participate in any of the meetings. 2. Review of Resident #1's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, polyneuropathy, peripheral vascular disease, chronic pain syndrome, hyperlipidemia, conductive hearing loss, anxiety disorder, epilepsy unspecified not intractable without status epilepticus, and tachycardia. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and Resident #1 required supervision with eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, personal hygiene, rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers, and walking ten feet. Resident #1 also was assessed to receive hospice services. Review of Resident #1's hospice care plan dated 07/12/24 revealed Resident #1 had a terminal prognosis and received hospice services related to cerebral atherosclerosis. Interventions included administer medications as ordered, consultation with the hospice team to ensure needs are met, encourage the resident to express feelings as needed, hospice to assist with care as needed, and staff to provide one-on-one as needed. Review of Resident #1's hospice order dated 07/18/24 revealed the resident was admitted to hospice for cerebral atherosclerosis. Review of Resident #1's hospice provider documentation from 02/07/25 to 06/25/25 revealed the facility did not have any hospice provider notes or communications related to Resident #1's needs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 16 of 17 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 06/26/2025 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 0849 medical status. Level of Harm - Minimal harm or potential for actual harm Interview with Assistant Director of Nursing (ADON) #236 on 06/25/25 at 7:52 A.M. revealed the facility had a hospice communication binder. ADON #236 verified the facility did not have any hospice provider notes or communications related to Resident #1's needs and medical status from 02/07/25 to 06/25/25. Residents Affected - Few Interview with Social Services (SS) #275 on 06/26/25 at 8:20 A.M. revealed the facility had not received any hospice provider notes or communications related to Resident #1's needs and medical status from 02/07/25 to 06/25/25. SS #275 confirmed she had not had any communication with Resident #1's hospice provider from 02/07/25 to 06/24/25. Review of the hospice contract with the facility, dated 02/12/25, revealed under section 2.1.3, Coordination, Supervision, and Evaluation of services, the hospice agency will promote open and frequent communication in person, by telephone, by facsimile, or in writing concerning the hospice plan of care and hospice patient's needs. Review of the facility policy titled, Hospice Program, dated 07/2017, revealed it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative. Communication with the hospice provider and documentation of communication to ensure needs of the residents are met. Additionally, the policy revealed the coordinated care plan for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365022 If continuation sheet Page 17 of 17