Health inspection·April 21, 2022

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. Based on medical record review and staff interview, the facility failed to notify the state mental health authority of a change in resident's mental health status. This affected one (#22) of one resident reviewed for Pre-admission Screening and Resident Review (PASARR) during the annual survey. The facility census was 33. Findings include: Review of Resident #22's PASARR dated 07/25/18 was silent in section D indicating Resident #22 did not have any indications of serious mental illness. Review of Resident #22's medical record revealed an admission date of 07/26/18. Diagnoses included but were not limited to the following: cerebral infarction, acute and post procedural respiratory failure, left hand contracture, left elbow contracture, difficulty in walking, cognitive communication deficit, major depressive disorder, and unspecified psychosis. Review of Resident #22's psychiatric follow up evaluation, dated 04/22/21, revealed Resident #22 had a history of depression, psychosis, sexually inappropriate behaviors, and personality disorder. The notes indicated Resident #22's issues started after the cerebral vascular accident in 2018. Further review of Resident #22's medical record revealed additional diagnoses of anxiety, personality disorder, and delusional disorder were added on 04/23/21. Further review of Resident #22's medical record revealed Resident #22 had additional psychiatric visits on 07/21/21, 08/31/21, and 09/28/21. Resident #22 had been receiving weekly individual therapy sessions with a psychologist that began 11/23/21 and continued to have weekly therapy sessions through the annual survey conducted in April of 2022. Additional review of Resident #22's medical record revealed no additional PASARR assessments. During interview on 04/20/22 at 8:59 A.M., Social Worker #406 stated if a resident developed a new psychiatric diagnosis, new behaviors, or requires psychiatric services, a new PASARR would need completed. Social Worker #406 confirmed Resident #22 had developed anxiety, personality disorder, and delusional disorder in 2021 and required psychiatric services starting in November 2021 and continuing through present. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy review, the facility failed to include residents and/or their representatives in care planning meetings and conduct quarterly care plan meetings. This affected three (#3, #8, and #29)of four residents reviewed for Care Planning during the annual survey. The facility census was 33. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 03/19/18, with diagnoses including: Alzheimer's disease, cognitive communication deficit, muscle weakness, dysphagia, Post-Traumatic Stress Disorder, Hypertension, Acute necrotizing hemorrhagic encephalopathy, and altered mental status. Review of Resident #8's medical record was silent for Care Conference notes. Review of Resident #8's profile contained three contacts with phone numbers, two of which were designated as a Care Conference Person. Interview with Registered Nurse (RN) #550 on 04/20/22 at 11:31 A.M., revealed no evidence of Care Conference for Resident #8 for the prior 12 months. 2. Review for Resident #3's medical record revealed an admission date of 07/15/21, with diagnoses including: traumatic hemorrhage of left cerebrum with loss of consciousness, cellulitis and abscess of the mouth, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/22/22, revealed this resident was not able to complete a Brief Interview for Mental Status (BIMS). This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, one-person extensive assistance with eating, and two-person total dependence with bathing. Review of the care conference records for Resident #3 revealed only one care conference was completed, which was on 07/19/21. Review of the progress notes from 07/15/21 through 04/21/22 revealed Resident #3 didn't have documentation regarding care conference minutes. Interview on 04/19/22 at 1:36 P.M. with the Administrator revealed Resident #3 had a care conference on 07/19/21 and had not had any care conferences since. Interview on 04/20/22 10:10 A.M. with the Director of Nursing (DON) confirmed Resident #3 had only had one care conference on 07/19/21 since his admission. 3. Review of Resident #29's medical record revealed an admission date of 10/21/21, with diagnoses including: chronic pain, anxiety, major depression, vascular dementia and hemiplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson 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 0657 cognition. The resident had a daughter involved with her care. Level of Harm - Minimal harm or potential for actual harm Review of a telephone care conference notes dated 11/01/21 revealed the Director of Nursing (DON) discussed care with the resident's daughter who expressed concerns about the resident's depression. There was no evidence of a care conference after 11/01/21. Residents Affected - Few Interview with the Director of Nursing on 04/20/22 at 12:43 P.M., verified last care conference for Resident #29 was conducted on 11/01/21 with no additional quarterly care conferences. Review of the facility policy title, Family Involvement in Resident Care, dated November 2020 revealed residents and their representatives will be provided with an opportunity to participate in the care planning process and be included in decisions, changes of care, treatment, and/or interventions. The social services department will send an invite to the resident's family for the quarterly care plan meeting via mail two weeks prior to the meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure the medication error rate was less than five percent. The facility had two errors of 27 opportunities resulting in a 7.41% error rate. This affected one (#36) of six residents observed during medication pass. The facility census was 33. Residents Affected - Few Findings include: Review of the medical record revealed Resident #36 admitted on [DATE], with diagnoses of right lower limb cellulitis, mild primary open-angle glaucoma, age-related bilateral nuclear cataract, type II diabetes, and Stage III chronic kidney disease. Review of Resident #36's physician orders for Latanoprost Solution 0.005% instill one drop in both eyes at bedtime and Timolol Maleate Solution 0.5% instill one drop in both eyes at bedtime related to primary open-angle bilateral mild stage glaucoma. Observation on 04/18/22 at 9:05 P.M., Licensed Practical Nurse (LPN) #140, looked in the medication cart and medication room but did not locate Resident #36's Latanoprost or Timolol eye drops. Interview on 04/18/2022 at 9:11 P.M., LPN #140 verified Resident #36's eye drops were not available and stated both medications had been re-ordered but had not been sent from the pharmacy. Review of policy titled Medication Administration: General Guidelines dated 05/2016, revealed medications were administered according to physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 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 365187 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/21/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Xenia Health and Rehab 126 Wilson 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on medical record review, physician and staff interviews, the facility failed to timely notify the physician of critical lab results. This affected one (#25) of three residents reviewed for hospitalization. The facility census was 33. Findings include: Review of the medical record of Resident #25 revealed an admission date of 01/20/22. Diagnoses included breast cancer, acute kidney failure, constipation, major depressive disorder, history of COVID-19, paroxysmal atrial fibrillation, morbid obesity, anemia, history of displaced intertrochanteric fracture of right femur, hyperlipidemia, congestive heart failure, seizures, cerebral aneurysm, and essential hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 03/22/22, revealed the resident had moderately impaired cognition. The resident did not exhibit any behaviors during the assessment period. The resident was dependent on two staff for bed mobility, transfers, and toileting and extensive assistance of one staff for eating. Review of a progress note dated 02/21/22 at 8:35 A.M., Resident #25 presented with increased fatigue, poor skin turgor with tenting, and was unable to hold a cup of water without assistance. Stat labs were ordered. Review of laboratory blood work dated 02/21/22 revealed Resident #25's calcium level was critically high at 14.5. Review of progress notes dated 02/21/22 through 02/23/22 revealed no evidence of the physician being notified of Resident #25's critically high calcium level. Review of a progress note dated 02/24/22 at 6:20 P.M., revealed Registered Nurse (RN) #105 spoke with the physician regarding Resident #25's abnormal labs and decreased oral intake. Orders were received to start 2 liters of clysis. Interview on 04/20/22 at 1:35 P.M., the Director of Nursing (DON), stated the expectation is to call the physician and notify of critical labs in a timely manner. The DON affirmed there was no documentation of the physician being notified of Resident #25's critical calcium level until 02/24/22. Interview on 04/21/22 at 10:35 A.M., with Physician #650 stated he ordered the clysis in the facility, upon being notified of Resident #25's critical calcium level. Interview on 04/21/22 at 11:04 A.M., the DON stated the facility did not have a written notification policy regarding physician notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365187 If continuation sheet Page 6 of 6