Inspection·May 23, 2019

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview; the facility failed to provide a skilled nursing facility Advanced Beneficiary Notice (ABN) to a resident who was discharged from Medicare A services when benefit days were not exhausted and the resident remained at the facility. This affected one resident (#69) of three residents reviewed for beneficiary notices. The facility census was 101. Residents Affected - Few Findings include: Review of Beneficiary Protection Notification for Resident #69 showed Medicare A services ended on 03/14/19. There was no evidence the resident was provided an ABN to the resident. Review of Resident #69's electronic medical record confirmed the resident remained in the facility when Medicare A services ended on 03/14/19. Interview with the Administrator on 05/23/19 at 2:13 P.M., verified the ABN was not provided to the resident. The Administrator revealed the facility staff attempted to complete the process appropriately, however due to the resident's behavior and family dynamics, they were not able to do so. The Administrator confirmed the ABN should have been provided to notify the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 2 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, the facility failed to provide a written bed hold information to a resident and/or the representative when the resident was hospitalized . This affected one resident (#347) of three reviewed for hospitalizations. The facility census was 101. Findings include: Review of Resident #347's medical record revealed an admission date of 04/04/19. Diagnoses included dementia, Parkinson's disease, and post-traumatic stress disorder. Review of the Medicare 14-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #347 was discharged from the facility to the hospital with an anticipated return on 04/17/19. Review of progress note dated 04/17/19 indicated Resident #347 was sent to the hospital and admitted for altered mental status. Interview on 05/22/19 at 4:32 P.M., revealed Resident #347 reported he did not receive any notices when he was sent to the hospital and admitted . Interview on 05/23/19 at 10:11 A.M., with the Assistant Director of Nursing (ADON) #355 revealed she verbally spoke to the Power of Attorney (POA), however did not issue any bed hold notifications to the resident or the POA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 3 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, the facility failed to develop a baseline care plan to address resident needs within 48 hours of admission. This affected one resident (#297) of 32 reviewed for baseline care plans. The facility census was 101. Findings include: Review of Resident #297's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified open wound of abdominal wall, methicillin resistant staphylococcus aureus (MRSA) infection, major depressive disorder-single episode, morbid obesity due to excess calories, and atherosclerotic heart disease. There was no evidence a baseline care plan had been completed. Interview on 05/20/19 at 3:28 P.M., with Resident #297 revealed the resident was not given a copy of a 48 hour care plan. Interview with the Director of Nursing (DON) on 05/22/19 at 08:49 A.M., verified the baseline care plans were not completed for Resident #297, and should have been within 48 hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 4 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observations, personnel record review, staff interview, and review of facility policy, the facility failed to provide, and individualized activity program designed to meet the interests and total care needs of the residents. This affected all eighteen residents (#1, #13, #19, #20, #22, #24, #29, #37, #46, #51, #54, #62, #64, #66, #67, #86, #91, and #347) who resided on the dementia unit. The facility census was 101. Residents Affected - Some Findings include: Observations on 05/20/19 at 9:33 A.M., on the dementia unit revealed residents in the common area, residents in their rooms or in front of the nurses' station. There were no activity calendars in residents' rooms for the current month. Some of the rooms had an activity calendar dated February 2019. There were no activity calendars at the nurses' station. No activities were observed to be going on. Observations on 05/20/19 at 10:47 A.M., revealed residents in the common area, residents in their rooms or in front of the nurses' station. No activities were observed to be going on. Observations on 05/21/19 at 6:20 P.M., revealed residents in the common area, residents in their rooms or in front of the nurses' station. No activities were observed to be going on. Observations on 05/22/19 at 10:00 A.M., revealed residents in the common area, residents in their rooms or in front of the nurses' station. No activities were observed to be going on. Interview on 05/22/19 at 10:45 A.M., with Licensed Practical Nurse (LPN) #305 revealed the facility had a dementia coordinator and an activity assistant specially for the unit, however the program was cut due to new management since February 2019. LPN #305 revealed the facility was in the process of hiring an activity assistant. LPN #305 stated State Tested Nursing Assistants (STNAs) provided activities in between caring for the residents. Interview on 05/22/19 at 10:52 A.M., with Activity Manager (AM) #495 revealed she had taken the position February 2019. AM #495 stated she was aware there was room for improvement in activities on the dementia unit. AM #495 verified there was no current activity calendar placed in residents' rooms. Interview on 05/22/19 at 11:14 A.M., with State Tested Nursing Assistant (STNA) #325 revealed the facility no longer had an activity assistant who would be on the unit. STNA #325 revealed some of the residents on the unit were invited to participate in activities held in healthcare on the first floor. Review of AM #495's personnel filed revealed the AM received a disciplinary action on 04/03/19 due to no activities being held on the dementia unit. Review of the facility policy titled, Daily Programming, revealed it was the policy of this care center to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program of activities will include a combination of large and small group, one to one, and self-directed activities. Involve each resident in an ongoing program of activities that is designed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 5 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0679 appeal to his or her interests. 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: 365278 If continuation sheet Page 6 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure that residents with contractures, received the necessary care and services to increase range of motion and/or prevent further decrease in range of motion. The affected one (Resident #95) of three residents reviewed for positioning and mobility. The facility identified 31 residents with contractures. The facility census was 101. Findings include: 1. Record review for Resident #95 revealed the resident was admitted to the facility in 11/2018. Diagnoses included persistent vegetative state, acute and chronic respiratory failure with hypoxia, anoxic brain damage, convulsions, quadriplegia, contracture unspecified hand, contracture unspecified elbow, and contracture unspecified wrist. Review of the Minimum Data Set (MDS) assessment, dated 04/30/19 identified the resident as being in a persistent vegetative state, and requiring the physical assistance of one to two staff persons to complete all activities of daily living, Resident #95 was identified as having functional limitations in his range of motion (ROM) of both upper and lower extremities. Review of an Occupational Therapy (OT) evaluation and plan of treatment, dated 03/08/19, revealed the reason for the evaluation was the resident was referred to OT for splinting both hands to prevent contracture and to maintain skin integrity. The evaluation documented the resident had swan neck deformities of digits two through five of both hands, and documented that the skilled OT services were warranted to design and implement restorative nursing programs and to improve ROM of upper extremities, staff training for splinting in order to enhance the resident's quality of life by decreasing the risk of contracture and maintaining skin integrity. Review of Resident #95's physician orders, dated 04/26/19, revealed an order for the resident to receive Occupational Therapy (OT) three to five times a week for four weeks for splinting, manual therapy, and caregiver training. Review of the OT Discharge summary, dated [DATE], revealed, at the time of discharge, the resident was able to tolerate bilateral resting hand splints for at least five hours at a time. The discharge recommendations noted a splint and brace program was established for the use of the bilateral upper extremity hand splints, and staff were trained on the use of the splints. Observation of the resident intermittently 05/20/19 and 05/21/19 revealed the resident was lying in bed and was without any splints applied to his hands. The resident appeared to have contractures of fingers of both hands. An interview was conducted with Licensed Practical Nurse (LPN) #525 on 05/22/19 at 9:20 A.M. regarding Resident #95's splint wearing schedule. LPN #525 reported she did not think the resident really needed splints but a family member wanted the resident to have OT and therapy complied. She shared the resident did tolerate the splints a couple hours a day, but then the family member will come in and put them on and take them off as they chose. LPN #525 was not aware of any specific schedule for the resident to wear the splints. When the resident's hands were observed with LPN #525, they appeared to have extension type contractures of fingers on both hands, and down-turned thumbs. LPN #525 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 7 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few showed this surveyor the resident's splints that were located in a drawer near his bed, verified he was not wearing them at the time. An interview was conducted with State Tested Nurse Aide (STNA) #220 on 05/22/19 at 9:45 A.M., who was caring for Resident #95 on 05/21/19 and 05/22/19. STNA #220 stated she was aware the resident did have splints, but was not sure of the resident's splint wearing schedule, or any specific care plan for wearing splints. She stated she thought that therapy was supposed to put them on, and then nursing staff take them off. STNA #220 verified the resident was not wearing them today, and he was not wearing them yesterday during her shift or so far today. An interview was conducted with Certified Occupational Therapy Assistant (COTA) #921 on 05/23/19 at 9:54 A.M. regarding Resident #95's hand splints and splint wearing schedule. COTA #921 stated she did not provide nursing staff with any specific written instructions regarding the resident's splints or splint wearing schedule when he was discharged from OT. She stated she did communicate with the nurse on the unit, LPN #525, and told her the resident was to wear the splints four to six hours a day. This surveyor reported the resident's resting hand splints had not been observed on the resident during the day shift of duty 05/20/19 through 05/22/19, and application of the splints were not included on the resident's care plan card used by the STNA's when caring for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 8 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician orders for obtaining daily weights and notifying the physician of a resident's weight gain for a resident receiving dialysis treatments. This affected one (Resident #40) of one resident reviewed for dialysis treatment. The facility identified four residents receiving dialysis services. The facility census was 101. Residents Affected - Few Findings include: Review of Resident #40's medical record revealed the resident was admitted on [DATE]. Diagnoses included dependence on renal dialysis, Chronic Kidney Disease (stage five), Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Type II Diabetes Mellitus with other diabetic kidney complication. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/09/19, revealed the resident's cognition was intact, the resident was 70 inches tall and weighed 196 pounds. The resident was on a prescribed weight loss regimen with a documented weight loss of five percent or more in the last month or 10% or more in the last six months. The resident was receiving peritoneal dialysis treatments. Review of a physician's order, dated 04/06/09, revealed to continue daily weight and keep a record and to notify the primary care physician if the resident gained two to three pounds in one day or five pounds in one week. Review of the Weight Log for 05/2019 revealed Resident #40's weights were as follows: on 05/05/19 at 203 pounds, on 05/06/19 at 205.5 pounds, on 05/10/19 at 202 pounds, and on 05/11/19 at 204.2 pounds. There were missing daily weights as physician ordered. Review of the progress notes for 05/2019 showed there was no documentation of Resident #40's primary care physician being notified of the resident's weight gains on 05/06/19 and 05/11/19. Interview with the Director of Nursing (DON) on 5/23/19 at 10:54 A.M. confirmed there was no documentation indicating Resident #40's primary care physician had been notified of the resident's weight gains on 05/06/19 or 05/11/19. The DON verified the resident's daily weights were not completed as physician ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 9 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, review of menus, and review of recipes for pureed menu items, the facility failed to follow the planned menus approved by a Registered Dietitian (RD). This affected seven residents who were ordered to receive pureed foods (#1, #52, #54, #68, #77, #85 and #86). The facility census was 101. Findings include: Review of the planned menu approved by a RD revealed it included the following items for residents on a pureed diet: a number 10 (3.2 ounces) scoop of pureed Salisbury steak with gravy, a number eight scoop (four ounces) of pureed noodles, and a number eight scoop (four ounces) of pureed vegetables. Review of the facility's list of residents on a pureed diet revealed Resident #1, #52, #54, #68, #77, #85 and #86 received a pureed diet. Observation of food preparation and service of the lunch time meal on 05/22/19 beginning at 10:46 A.M. revealed [NAME] #565 was observed getting ready to puree the meat for the lunch time meal. Observation of the food processor revealed a small amount of sliced beef was in the bottom of the processing bowl, and on top of the meat were numerous slices of bread. At that time, Dietary Manager (DM) #810 also came into the kitchen to observe [NAME] #565. [NAME] #565 was asked what exactly was added to the food processor bowl. She stated she first added about a pound of beef in the processor, and then in front of the surveyor counted out the 17 slices of bread that were added on top of the beef. [NAME] #565 was asked if she had weighed the beef slices before adding them to the food processor she stated she had not. When asked if she had a recipe to follow for the pureed Salisbury steak, or pureed beef, she stated there were recipes but stated she did not have any recipes out. DM #810 then stated there were recipes and would print the recipe out for the pureed beef/Salisbury steak. When [NAME] #565 and DM #810 were asked how many residents were on pureed diets, they both reported six residents were on pureed diets, plus one additional resident was on a mechanically soft diet with pureed meat. [NAME] #565 then pureed approximately one pound of beef and the 17 slices of bread, adding beef broth until it was smooth, and placed the pureed meat in a pan on the steam table. [NAME] #565 verified she was not using the same Salisbury steak product that the regular diets were being served. The cook said she used the leftover meat from the night before, which was from the beef and cheddar sandwiches, and said she was using this for both the pureed diets and mechanically soft diets. Regular diets were receiving a four ounce portion of a prepared Salisbury steak product. On 05/22/19 at 11:05 A.M., an interview with [NAME] #565 stated she was serving mashed potatoes to the residents on a pureed diet, instead of the noodles that were on the approved menu by a RD. She stated noodles did not puree well. Review of the facility's recipe for pureed Salisbury steak revealed it did not include any bread in the recipe. The recipe for pureed Salisbury steak included meat and the minimal amount of liquid needed to make the meat smooth. Interview with DM #810 on 05/22/19 at 12:15 P.M. verified [NAME] #565 did not follow the facility's puree recipe for Salisbury steak. She verified the cook did not use the Salisbury steak the recipe called for and the cook used 17 slices of bread which the recipe said not to use any bread. The DM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 10 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0803 also verified the cook did not follow the planned menu for pureed noodles. 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: 365278 If continuation sheet Page 11 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policy, the facility failed to ensure that leftover frozen food was stored in a manner to prevent dehydration and oxidation/freezer burn and to maintain the quality of the food served. This had the potential to affect 99 of 101 residents of the facility who received food from the kitchen. Resident #14 and #95 received no food by mouth. Findings include: A tour of the central kitchen was conducted with Dietary Manager (DM) #810 on 05/20/19 at 8:55 A.M. While touring the kitchen, the walk-in freezer was examined. Observation of the walk-in freezer revealed the following: a) There were two metal sheet trays of small pizzas loosely wrapped with plastic wrap that did not cover the pizza and the pizza crust appeared freezer burnt. b) There was a full 12 inch by 20 inch pan of left over shepherds pie (mashed potatoes and beef mixture) dated 02/02/19 with the foil covering the product ripped off exposing mashed potatoes that were dried out and freezer burnt. There was an accumulation of ice crystals on the top of the mashed potatoes. c) There was a full 12 inch by 20 inch pan of beef stew covered with ripped foil and plastic wrap which was partially frozen onto the top of the product. The beef stew appeared dried out and freezer burnt and the date on the foil was illegible. When asked if she knew when beef stew was last on the menu, DM #810 stated that beef stew had not been on the menu for some time. d) There was a one fourth pan only partially covered with foil labeled to be corned beef dated 01/07/19. In the pan, there were several slices of discolored, white dried out slices of corned beef. e) There was a one fourth pan with a large hole through the foiled covering the frozen product labeled barbeque pork with a date of 02/18/19. The pork appear dried out and discolored. f) There was a sheet tray of fish portions loosely wrapped with foil with the fish portions exposed to the air. The fish portions were undated. Interview with DM #810 at the time of the observations verified the frozen food items were improperly wrapped and stored to prevent freezer burn. Review of the facility's list of residents who received no food by mouth (NPO) revealed Resident #14 and #95 were NPO. Review of the facility policy and procedure titled Leftovers specified that leftovers shall be stored in a safe and sanitary manner to maintain food safety and quality. The procedure specified that leftovers cannot be used as alternate unless requested by residents. They may be used as an extra or incorporated into a different menu item as an alternate. The policy did not specify how long the facility would maintain left overs in the freezer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 12 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview and facility policy review, the facility failed to ensure medications were administered in a hygienic manner. This affected two residents (Resident #5 and #38) of three residents observed during medication administration. This had the potential to affect 11 residents who receive eye drops and 16 residents who receive insulin in the C and D halls. The facility also failed to implement a water management program for the prevention and spread of Legionella. This had the potential to affect all 101 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the medical record of Resident #38 revealed an admission date of 12/19/13 and a readmission date of 10/24/14. Diagnoses included diabetes mellitus type two and legal blindness. Review of the physician orders for May 2019 revealed an order for Lantus (insulin) five units administered subcutaneously twice daily. An order Timoptic Solution 0.5% instill one drop in right eye twice daily. Observation on 05/22/19 at 8:00 A.M. of the medication administration revealed Registered Nurse (RN) #160 prepared an injection of Lantus five units, after priming the needle, for Resident #38. RN #160 entered the room of Resident #38 with the insulin pen, a plastic medication cup with various tablets and capsules, a plastic medication cup with a liquid medication and a bottle of Timolol Maleate zero point five percent eye drops. RN #160 gave the plastic medication cup with the tablets and capsules to Resident #38 who took them orally. She then handed him the cup with the liquid medication, which he took. RN #160 then administered one drop of the eye drop to the right eye of Resident #38 without first applying gloves or washing her hands. RN #160 proceeded to inject the five units of insulin into the left arm of Resident #38 without washing her hands or applying gloves. Interview on 05/22/19 at 8:04 A.M. with RN #160 verified she had not worn gloves while administering insulin and or eye drops. She further verified she had not washed her hands after administering eye drops and prior to administering insulin. 2. Review of the medical record of Resident #5 revealed an admission date of 04/25/16. Diagnoses included diabetes mellitus type two,chronic kidney disease and Parkinson's disease. Review of the physician orders for May 2019 reveled an order for OcuSoft Lid Scrub Pad, an eye lid cleanser, to be applied to eyelids topically once daily for dry eyes. An order for Basaglar solution (insulin) inject 31 units subcutaneously twice daily. Observation on 05/22/19 at 8:18 A.M. of the medication administration revealed Licensed Practical Nurse (LPN) #140 prepared an injection of Basaglar 31 units, after priming the needle, for Resident #5. LPN #140 entered the room of Resident #5 with the insulin pen, a plastic medication cup with various tablets and capsules, and a packet containing Opti Soft Lid Cleanser swab. LPN #140 handed Resident #5 the plastic medication cup and obtained a bottle of apple butter, identified by LPN #140, from the small refrigerator in the room. Resident #5 placed tablets and capsules on his tongue and LPN #140 offered him a spoonful of apple butter after every mouthful of medications. LPN #140 proceeded to open the small packet of Opti Soft Lid Cleanser and removed the swab and wiped the left eye with the swab, turned the swab over and wiped the right eye. LPN #140 had not washed her hands nor applied gloves prior to administering the eye lid cleanser. LPN #140 proceeded to administer the 31 units (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 13 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 0880 of insulin to the left mid abdomen of Resident #5 without applying gloves or washing her hands. Level of Harm - Minimal harm or potential for actual harm Interview on 05/22/19 at 8:19 A.M. with LPN #140 verified she had not worn gloves while administering insulin and or eye drops. She further verified she had not washed her hands after administering insulin and prior to administering eye lid scrub. Residents Affected - Many Review of the facility policy tilted Hand Washing undated, revealed hands were to be washed before and after resident contact. 3. Review of the facility's Legionella water management program log sheets revealed there were no chlorine levels recorded. Interview on 05/23/19 at 11:00 A.M. with the Maintenance Director (MD) #820 reveled no chlorine levels have been obtained to ensure safe levels. Review of the facility water management program titled Developing a Legionella Water Management Program undated, revealed the disinfectant levels should be monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 14 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to maintain residents' room environment in a clean, sanitary and in a comfortable manner. This affected 19 residents (#2, #9, #18, #19, #24, #36, #40, #47, #48, #49, #53, #54, #55, #57, #60, #64, #67, #71 and #95) observed for environment. The facility census was 101. Findings included: 1. Observation on 05/20/19 at 9:05 A.M., revealed Resident #54 and Resident #64 room's (212) privacy curtains were stained throughout. Observation at 9:52 A.M., revealed Resident #19 room (217) had six inches of marks and scrapes exposing the dry wall on the right side of the recliner, there were also scrapes and marks behind the recliner on the wall exposing the drywall. There was also a five-foot heat cover that was supposed to cover the pipes, but it was on the floor leaving pipes uncovered. Interview at 9:55 A.M., with Resident #19 revealed the scrapes on the walls were there when he was admitted as of 02/14/18. Observation on 05/20/19 at 5:37 P.M., revealed Resident #24 and #67's baseboard was hanging apart near the closet door, the cord for heat vent was on the floor, and both privacy curtains were stained. Interview on 05/21/19 at 2:08 P.M., with Regional Management (RM) #810 reported everything was completed due to priority and severity. Staff completes a work order and sends it to the maintenance director and repairs should be completed that day. There were no work orders in place for the mentioned repairs. RM #810 verified findings of stained privacy curtains in the rooms of Resident #24, # 54, #64 and #67, verified exposed drywall in Resident #19 walls and the heat cover lying on the floor, and verified findings baseboard hanging along with heating cord on the floor. Review of facility policy titled, Drapery Cleaning (undated) revealed housekeeping is to inspect drapes and report any torn, stained, soiled or deteriorated drapes to the supervisor. Drapes should be vacuumed at least quarterly to be maintained properly. 2. Observation on 05/22/19 at 10:30 A.M., revealed Resident #9 in room (167) reported in March 2019 the tile was missing in front of his toilet. RM #810 verified there was missing tile in front of Resident #9's toilet. Observation at 11:00 A. M., revealed Resident #60, Resident #71 in room (127), Resident #55 and Resident #57 in room (143) reported in 05/2019 their toilet paper holder was broken. Resident #53 in room (128) reported a mirror in the bathroom was broken. Resident #40 in room (166) reported the light switch above bed did not work. Observation of the above items were verified by RM #810. 3. A tour of the second floor, long term care unit, with Maintenance Director (MD) #820 on 05/22/19 at 4:44 P.M., revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 15 of 16 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 365278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Troy Rehabilitation and Healthcare Center 512 Crescent Drive Troy, OH 45373 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 a) There was a light cover missing off a wall sconce in the hallway outside room [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm b) In the room occupied by resident #48 the wall bumper which ran behind both beds in the room was hanging off the wall, the air conditioner cover of the wall unit was duct taped in place, and the screen to the window did not fit which the resident reported allowed insects to come in her room. Residents Affected - Some c) In the room occupied by residents #18 and #2 the wall around the magnet which held the door open was damaged and recessed back into the wall. Resident #18, who was mobile via wheel chair, shared due to the magnet recessing into the wall it was difficult to independently open the door and keep it open as the door was self-closing. d) In the room occupied by Resident #36 there was a receptacle cover cracked off at the top exposing the junction box below. e) In the room occupied by Resident #47 and #49 there were multiple holes and scrapes in the wall behind Resident #47's bed, and the cove base was falling off the wall behind Resident #49's bed. f) In the room occupied by Resident #95 there were three lay-in ceiling tiles water damaged and stained with dried on rust colored rings. The tiles were located to the right of the resident's bed. At the conclusion of the tour MD #820 and the Administrator revealed nurses, nurse aides, and other staff can submit paper work orders which were in a small wall mounted bin located in the corridor. There were no evidence any work orders had been submitted for the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 16 of 16