Inspection·June 13, 2022

F 0656 ordered/recommended. Level of Harm - Minimal harm or potential for actual harm 2. Review of medical record revealed Resident #13 was admitted on [DATE] with diagnoses of Parkinson disease, upper respiratory infection, dysphagia, malnutrition, and depression. Residents Affected - Few The physician ordered a mechanical altered diet, a supplement three times a day for risk of malnutrition and tube feeding of Jevity 1.5 at 65 milliliters per hour from 7:00 P.M. to 7:00 A.M. Review of the MDS dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff person for meal assistance. The nutrition plan of care dated 05/23/22 revealed the resident was at risk for aspiration, swallowing problems, and chronic weakness. The Dietetic Technician # 605 entered an intervention on 03/18/22 to provide adaptive equipment curved utensils to aid with feeding self. Interventions also included provide feeding assistance as needed and provide nutrition supplement as ordered. Review of diet orders received by DM #618 from 01/19/22 through 06/09/22 revealed a diet order of adaptive curved utensil on 01/19/22 and no discontinue order for the adaptive utensils. Review of the lunch meal tickets dated 06/08/22 and 06/09/22 revealed no documentation of adaptive curved utensils. Observation on 06/06/22 at 1:24 P.M. revealed the Resident #13 up in wheelchair attempting to feed himself with plastic utensils. There was no adaptive device on the utensils. The resident's food was scattered over the Styrofoam container, onto the tray and noted on the clothing protector on the resident's chest. The resident consumed approximately 50% of the meal. Interview on 06/07/22 with Resident #13 family representative, in resident room, revealed the resident has not received adaptive curved feeding utensils for several weeks during her daily lunch mealtime visits. She stated the resident attempts to feed himself with contracted hands but cannot open foods or often cannot reach his mouth with regular utensils. She stated he has continued to lose weight. She stated no staff had offered a different type of adaptive equipment. Interview on 06/09/22 at 12:30 P.M., the Director of Nursing, (DON) # 608, stated Resident #13 adaptive feeding utensils had been discontinued from the plan of care on 06/07/22. Interview on 06/09/22 at 1:06 PM, Diet Manger, (DM) # 618 revealed she received a diet order from the nursing department on 01/19/22 for Resident #13 to have adaptive curved utensils. DM #618 revealed no diet order had been received to discontinue the adaptive curved utensils through 06/09/2. Interview on 06/09/22 at 1:24 PM, Certified Occupational Therapy Aide, (COTA) # 454 revealed on 01/17/22, she recommended and provided a diet order for Resident #13 adaptive curved feeding utensils to Diet Manager, (DM) # 618. COTA #454 denied notification of the need to reevaluate or discontinue adaptive feeding utensils for Resident #13 since 01/17/22. Interview on 06/09/22 at 1:59 P.M. with Diet Technician, (DTR) # 605 verified she had entered an intervention to provide adaptive equipment curved utensils to aid with feeding into the 05/23/22 plan of care on 03/18/22. She further stated she had not entered the intervention on 01/19/22 when COTA #454 had completed a diet order to begin adaptive feeding utensils. DTR #605 revealed she had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 2 of 11 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 06/13/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete received notification the adaptive equipment was to be discontinued from 03/18/22 through 06/09/22. DTR #605 verified the plan of care dated 05/03/22 continued to document Resident #13 was to receive curved utensils. Review of the facility policy titled, Goals and Objectives, Care Plan, dated September 2021, revealed Policy Statement: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Policy Interpretation and Implementation: 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 3. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. Event ID: Facility ID: 365278 If continuation sheet Page 3 of 11 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 06/13/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide meal assistance for one resident, (Resident #13) of three residents reviewed who required mealtime assistance. The facility census was 120. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted on [DATE] with diagnoses of Parkinson disease, upper respiratory infection, dysphagia, malnutrition, and depression. The physician ordered a mechanical altered diet, a supplement three times a day for risk of malnutrition and tube feeding of Jevity 1.5 at 65 milliliters per hour from 7:00 P.M. to 7:00 A.M. Review of the Minimum Data Set, (MDS) dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff person for meal assistance. The nutrition plan of care dated 05/23/22 revealed the resident was at risk for aspiration, swallowing problems, and chronic weakness. Interventions included provide feeding assistance as needed, provide nutrition supplement as ordered and adaptive curved utensils. Observation on 06/06/22 at 1:24 P.M. revealed the Resident #13 was up in wheelchair attempting to feed himself with plastic utensils. There was no adaptive utensils. The resident's food was scattered over the Styrofoam container, onto the tray and noted on the clothing protector on the resident's chest. T he resident consumed approximately 50% of the meal. Interview on 06/07/22 with Resident #13 family representative, in resident room, revealed she visits daily at lunch meal. She verified the resident attempts to feed himself with contracted hands but cannot open foods or often cannot reach his mouth with regular utensils. The staff had not been observed or offered to assist the resident with meals. She stated the resident had not received adaptive utensils to assist in feeding himself for several weeks and no staff had offered a different type of adaptive equipment. She stated he has continued to lose weight. Interview on 06/07/22 at 03:10 P.M. with the Registered Dietitian (RD) #453 revealed Resident #13 had a weight change from 12/13/21 of 162.7 pounds to 06/01/22 to 138 pounds and had been trending downward. The nighttime tube feeding had been increased and the supplement of magic cups had been increased to three times with meals. RD #453 stated the resident feeds himself but requires assistance with feeding due to contracted hands. Observation on 06/08/22 at 1:10 P.M. at the lunch meal, revealed Resident #13 sitting in wheelchair feeding himself ice cream from a small container barely in reach and was holding a small handled plastic spoon with contracted fingers. The supplement magic cup was not opened with a tight lid and the resident would not reach it. The food was scattered in the Styrofoam container and onto the tray. Interview on 06/08/22 at 1:12 P.M., State Tested Nurse Aide, (STNA ) # 443 verified she had not opened the supplement magic cup, the ice cream the resident could not hold and was not opened for him to access. She stated she was the resident intake varied from 25-75 % and was unaware he required extensive assistance for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 4 of 11 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 06/13/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 06/09/22 at 8:05 A.M. revealed the resident in bed with meal tray on over bed table. The resident appeared asleep with hand hold a silverware spoon without an adaptive device. The breakfast meal was 50% consumed. The supplement was not in reach and 0 % was consumed. Interview on 06/09/22 at 8:10 A.M. with Licensed Practical Nurse # 552 stated he falls asleep often at breakfast and staff don't wake him up to assist him with breakfast. Observation on 06/09/22 1:57 P.M. breakfast tray was in Resident #13 room on a chair with less than 25 % consumed. Resident #13 up in wheelchair with lunch meal with no adaptive utensil to assist with meal. Family Representative at bedside stated no staff had assisted him with meal other than to set up and open items on the tray. She verified he was unable to open, hold and reach the containers on the tray of dessert, and supplement. Interview on 06/09/22 at 1:24 PM, Certified Occupational Therapy Aide, (COTA) # 454 revealed at the conclusion of therapy session from 01/12/22 through 01/21/22, Resident #13 required feeding assistance due to bilateral hand contracture's and was not a candidate for splints. Review of facility policy titled Assistance with Meals dated September 2021, revealed the facility staff will serve and help residents who require assistance with eating. Adaptive equipment will be provided for residents who need them including devices for silverware with enlarged handles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 5 of 11 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 06/13/2022 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 0692 Provide enough food/fluids to maintain a resident's health. 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 and staff interviews the facility failed to ensure a resident had physician orders for a therapeutic diet. This affected one of (#110) of five residents sampled for nutrition. The facility census was 120. Residents Affected - Few Findings include: Review of the medical record for Resident #110 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, fluid volume overload and lung cancer. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment and required supervision with eating. The MDS assessment did not indicate Resident #110 was receiving a therapeutic diet while in the facility. Review of the resident's hospital coordination of care report received by the facility's Director of Marketing and Admissions #603 on 04/29/22 at 11:51 A.M., revealed orders for a therapeutic diet of no added salt and low K+ (potassium). Review of Resident #110's hospital discharge instructions/orders dated 05/06/22 revealed dietary orders to maintain the renal Hemodialysis (HD) orders for no added salt and low potassium (K+) diet. Review of the Renal Dietician Recommendation Form dated 05/12/22 revealed facility specific recommendations, diet orders to limit high potassium foods. Review of Resident #110's June 2022 physician orders revealed a diet order dated 05/07/22 for a regular diet, regular texture, and thin consistency. The dietary order did not indicate Resident #110's no added salt and low potassium diet. On 06/09/22 at 8:16 A.M., during an interview Registered Dietician Licensed Dietician (RDLD) confirmed, Resident #110's physician orders were not specific to the type of therapeutic diet the resident was ordered/recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 6 of 11 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 06/13/2022 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 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 and interview the facility failed to provide medication as ordered. This affected one Resident #365 of five residents reviewed for medication administration. The facility census was 120. Findings include: Medical record review for Resident #365 revealed admission date 05/20/22 and discharge date [DATE]. Diagnoses included osteomyelitis of vertebra, lumbar region, inflammatory spondylopathies, low back pain, and chronic pain. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired cognition. The resident required extensive one-person assistance for bed mobility and extensive two-person assistance for transfers. The resident received scheduled and as needed pain medications. The assessment revealed occasional pain over the last five days. Pain was rated at eight on a one to ten scale. Review of the Plan of Care dated 05/23/22 revealed the resident had potential for pain related to chronic pain. Interventions included to administer medications per physician order and monitor for side effects and effectiveness. Review of physician orders revealed oxycodone 20 mg give one tablet by mouth for pain for seven days, start date 05/25/22, discontinued 06/01/22, oxycodone 20 mg, give one tablet by mouth every six hours for pain for 14 days, start date 06/01/22, and acetaminophen 1000 mg every eight hours as needed for pain, administered 06/06/22 at 8:54 A.M., pain rated six of ten and assessed as effective. Resident to have consult with pain clinic per physician one time only for pain management. Pain management appointment on 06/17/22 at 1:15 P.M. Review of the Medication Administration Record (MAR) for June 2022 revealed the resident did not receive on oxycodone 20 mg on 06/04/22 at 6:00 A.M. and at 12:00 P.M. Review of the narcotic sign out sheet for June 2022 with the Director of Nursing (DON) revealed Resident #365 received oxycodone 20 mg on 06/04/22 at 12:00 P.M. The sign out sheet revealed the medication was removed from a new blister pack that contained 20 pills. The prior dose was administered on 06/03/22 at 6:43 P.M. and indicated the last pill had been given. The Narcotic sign out sheet revealed oxycodone 20 mg had not been administered on 06/04/22 at 12:00 A.M. and 6:00 A.M. Interview on 06/08/22 at 4:17 P.M. the DON stated a message had been sent out to the provider on 06/03/22 that resident needed new dose sent. The DON verified the medication had not been administered and was not available in the Omnicell. Review of the facility policy titled Pharmacy Services-Role of the Provider Pharmacy, undated, revealed the provider pharmacy should routine pharmacy service seven days a week and emergency pharmacy services 24 hours per day, seven days a week. Provide and maintain the facility's emergency medication supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 7 of 11 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 06/13/2022 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adaptive feeding utensils for two residents (Residents #13 and # 363) of three residents reviewed for assistance devices. The facility census was 120. Residents Affected - Few Findings include: 1. Review of medical record revealed Resident #13 was admitted on [DATE] with diagnoses of Parkinson disease, upper respiratory infection, dysphagia, malnutrition, and depression. The physician ordered a mechanical altered diet, a supplement three times a day for risk of malnutrition and tube feeding of Jevity 1.5 at 65 milliliters per hour from 7:00 P.M. to 7:00 A.M. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff person for meal assistance. The nutrition plan of care dated 05/23/22 revealed the resident was at risk for aspiration, swallowing problems, and chronic weakness. The Dietetic Technician # 605 entered an intervention on 03/18/22 to provide adaptive equipment curved utensils to aid with feeding self. Review of diet orders received by Dietary Manager #618 from 01/19/22 through 06/09/22 revealed a diet order of adaptive curved utensil on 01/19/22 and no discontinue order for the adaptive utensils. Review of the lunch meal tickets dated 06/08/22 and 06/09/22 revealed no documentation of adaptive curved utensils. Observation on 06/06/22 at 1:24 P.M. revealed the Resident #13 up in wheelchair attempting to feed himself with plastic utensils. There was no adaptive device or curved utensils. Interview on 06/09/22 at 1:06 PM, DM # 618 revealed she received a diet order from the nursing department on 01/19/22 for Resident #13 to have adaptive curved utensils. DM #618 revealed no diet order had been received to discontinue the adaptive curved utensils through 06/09/22. Interview on 06/09/22 at 1:24 PM, Certified Occupational Therapy Aide, (COTA) # 454 revealed on 01/17/22, she recommended and provided a diet order for Resident #13 adaptive curved feeding utensils to DM #618. COTA #454 denied notification of the need to reevaluate or discontinue adaptive feeding utensils for Resident #13 since 01/17/22. Observation on 06/08/22 at 1:10 P.M. at the lunch meal, revealed Resident #13 sitting in wheelchair feeding himself ice cream and was holding a small straight handled plastic spoon with contracted fingers. The food was scattered in the Styrofoam container and onto the tray. Observation on 06/09/22 at 8:05 A.M. revealed the resident was in bed with meal tray on overbed table. The resident appeared asleep with hand hold a silverware spoon without an adaptive device or curved handle. The breakfast meal was 50% consumed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 8 of 11 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 06/13/2022 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/09/22 at 1:59 PM, Diet Technician, (DTR) # 605 verified she had entered an intervention to provide adaptive equipment curved utensils to aid with feeding into the 05/23/22 plan of care on 03/18/22. She further stated she had not entered the intervention on 01/19/22 when the COTA #454 had completed a diet order to begin adaptive feeding utensils. DTR #605 revealed she had not received notification the adaptive equipment was to be discontinued from 03/18/22 through 06/09/22. DTR #605 verified the plan of care dated 05/03/22 continued to document Resident #13 was to receive curved utensils. 2. Record review of Resident # 363 revealed an admission date of 08/02/21 and diagnoses of heart failure, diabetes, dysphagia, cerebral infarction, and Parkinson Disease. Physician orders included a mechanical soft diet. Review of the MDS dated [DATE] revealed the resident had intact cognition and required supervision assistance of one staff person for meal assistance. Review of the Resident Equipment List provided by the facility, Resident #363 was identified to require built up utensil for all three meals. Observation of meal of lunch meal 06/06/22 at 12:15 P.M. revealed no adaptive built up utensils. Resident #363 was eating the meal with plastic utensils. Observation on 06/08/22 at 12:41 lunch meal, Resident #363 had no built-up utensil on the lunch tray. The resident was eating the meal with plastic utensils. Observation on 06/09/22 at 12:05 P.M., Resident #363 had built up utensil on lunch meal tray. Interview on 06/09/22 at 12:05 P.M. Resident #363 stated this was the first time he has had built up utensils on his meal tray for several weeks. Observation of meal ticket dated 06/09/22 at 12:06 P.M. verified Resident #363 was to have built up utensils on the lunch meal tray. Interview 06/09/22 at 12:06 P.M. Resident #363 stated to Activity Director # 607 and Diet Manger # 618, he had plastic utensils, not the built-up ones, until breakfast on 06/09/22. Diet Manger #618 verified Resident #363 had not received built up utensils on 06/06/22 and 06/08/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 9 of 11 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 06/13/2022 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to label, date and discard resident refrigerated foods on three nursing units, (Nursing Unit 100, Memory Care Unit and C-1/CD-1/D-2 Unit) of three units reviewed. This had the potential to affect 72 of 120 residents identified by the facility to receive foods on these units. The facility census was 120. Findings include: Observation on 06/09/22 at 8:19 AM resident food storage refrigerator on 100 unit revealed no temperature log was completed for dates of 06/03/22, 06/04/22, 06/05/22 and 06/08/22. One container of supplement, Med Pass, was not dated, and one was dated of 04/18/22. There were four containers of various foods including a soup container, meat container, fruit container and an unknown food container with no labels and dates. There was a sign on the outside door of the refrigerator, No Employee Food- all food must be labeled and dated. Interview on 06/08/22 at 8:20 A.M. with Licensed Practical Nurse (LPN) # 509 verified the supplement was expired, the supplement container not dated, and foods in containers were not labeled or dated. LPN #509 verified the refrigerator should be only for resident use and all foods must be labeled, dated and items removed if expired. Observation on 06/09/22 at 8:30 A.M. of resident food storage refrigerator on unit C-1/CD-1D-2, revealed supplement, Med Pass, was dated 06/01/22 and a bag with a decayed piece of fruit. The temperature log on the door was missing temperature dates of 06/07/22. There was a sign on the refrigerator door No Employee Food- all food must be labeled and dated. Interview on 06/09/2 at 8:32 A.M. with LPN # 552 verified the decayed fruit and expired supplement. LPN #552 verified food should be dated when opened and discarded after three days. LPN #552 stated it is night shift staff to record temperatures daily and maintain refrigerator food storage procedures. Observation on 06/09/22 at 12:14 P.M. the resident food storage refrigerator on the Memory Care unit revealed an unidentifiable food in a container which was not dated or labeled, three containers of a supplement, Med Pass, was not dated, two open soup containers not dated, and a bag of fruit was not label or dated. There was a sign on the refrigerator door No Employee Food- all food must be labeled and dated. Interview on 06/09/22 at 12:15 P.M. with State Tested Nurse Aide, (STNA) #484 verified the food was not dated, the three supplement containers were not dated and the bagged fruit was a staff member, which was not dated. STNA #484 verified the foods in refrigerator should only be for resident storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 10 of 11 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 06/13/2022 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. Based on observations and interviews, the facility failed to provide and maintain a clean resident smoking area. This affected 23 of 23 facility identified residents who smoke (Residents #39, #86, #45, #93, #89, #71, #370, #90, #68, #19, #55, #04, #15, #40, #92 ,#25, #82, #377, #07, #365, #02, #76, and #21). The facility census was 120. Findings include: Observation on 06/07/22 at 02:50 P.M. revealed two residents, Resident #76 and #71 in wheelchairs on the patio of the resident smoke area. Leading up to the patio area, an adjacent landscaped area of appropriately 10 feet by 20 feet was filled with stones, small sticks and dried peanut shells. There were greater than 50 extinguished cigarette butts in the landscaped area. Interview on 06/08/22 at 1:40 P.M. with Housekeeper #433 revealed on 06/08/22, she had cleaned the patio and cigarette butt filled area in the A.M. She verified the area is covered with sticks and peanut shells and had cigarette butts in the area daily. Interview on 06/08/22 at 1:50 P.M. with the Environmental Director #613 verified the resident smoke area was covered with sticks and dried peanut shells and had greater than 50 cigarette butts. She verified the area had not been cleared of cigarette butts this A.M. and had last been cleared of cigarette butts on 06/06/22. She verified the lawn care company had been at the facility in the A.M. and had not cleared the area of cigarette butts. She verified it was the responsibility of housekeeping to clear the area and maintain a safe resident area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365278 If continuation sheet Page 11 of 11