Inspection·May 16, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm residents are only allowed one cigarette per day, but could not clarify why residents only get one smoke break and only one cigarette daily. Interview on 05/11/22 at 9:40 A.M. with STNA #123 revealed residents get one smoke break daily and get one cigarette. STNA revealed the south unit residents had been restricted since COVID started. Residents Affected - Some Interview on 05/11/22 at 9:58 A.M. with Registered Nurse (RN) #106 revealed majority of the smokers are on the south unit of the facility. Interview on 05/12/22 at 9:50 A.M. with Resident #45 and #68 revealed they would like three smoke breaks daily one in the morning, afternoon, and evening. Residents revealed previous smoking history of smoking 1 to 3 packs per day and now they are only allowed one cigarette once daily. Interview on 05/12/22 at 9:52 A.M. with the Administrator revealed the south unit recently opened their doors from being a locked unit and residents can move freely around the facility. The Administrator revealed residents should be able to all go outside multiple times daily to smoke. Administrator revealed the sign posted was old and stipulated residents on south unit could only smoke one cigarette at all times. The Administrator revealed the schedule allowing south hall residents to only smoke once daily was old, and revealed being unaware residents on the south hall were not given equal smoking privilege's as other residents. Interview on 05/12/22 at 10:15 A.M. with DON revealed a plan to change the smoking schedule. DON revealed being unaware of when the provided schedule for smoking was created and how long it has been in effect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 2 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and observation, the facility failed to maintain all areas and equipment in good repair. This affected one resident (#55) of one resident reviewed for environment. The facility censes was 71. Findings include: Review of the medical record for the Resident #55 revealed an admission date of 07/13/20. Diagnoses included paraplegia, intracranial injury, spinal cord injury, immobility, depression, psychosis, schizophrenia, bipolar disorder, and muscle wasting. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively intact and required limited assist of one staff member. Observation and interview on 05/09/22 at 9:36 A.M. with Resident #55 revealed his bed remote cord rubber protectant was frayed exposing the wiring with intact rubber protectors. Resident also revealed large sections measuring about 3-6 inches by 2-3 feet across both the inside of the residents room and outside of the resident's bathroom. The residents bathroom door had a hole about the size of a quarter. Observations on 05/10/22 and 05/11/22 revealed the bed remote, main door and bathroom door remained in poor condition. Interview and observation on 05/12/22 on 9:47 A.M. with Maintenance Director (MD) #186 confirmed Resident #55's bed remote was frayed and confirmed damage to both the main door and bathroom door in residents room. MD stuck his finger in the hole in the bathroom door and it was about two inches deep. MD revealed bedroom door could likely be covered with paint but the bathroom door would need replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 3 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policy the facility failed to investigate and timely report an allegation of abuse. This affected one Resident (#06) of two residents reviewed for abuse. The facility census was 71. Residents Affected - Few Findings include: Review of medical record for Resident #06 revealed admission date of 01/17/21 with diagnoses including paralytic syndrome, type 2 Diabetes Mellitus, dementia, schizoaffective disorders, adjustment disorder, depression, anxiety. The resident remains at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed resident is cognitively intact, required extensive one assist for bed mobility, total dependence for dressing, toileting,transfer and supervision for eating. Interview on 05/09/22 at 11:45 A.M. with Resident #06 revealed a staff member had hit her on the right shoulder. She stated she had informed the nurse and was not sure what happened about it. Interview on 05/09/22 at 2:33 P.M. with the Administrator revealed she had not been informed by Resident #06 or any staff member of Resident #06's abuse allegation, but would speak to her. Interview on 05/11/22 at 12:45 P.M. with Social Services (SS) #177 revealed Resident #06 had informed her of a concern with an aid a couple weeks ago prior. SS #177 stated Resident #06 had informed her an aid had been physical with her, and recalled it had something to do with an aid hitting her on the shoulder. Resident #06 was unable to give aid name of the aid and her description was very broad, she was unable to recall the day or the shift. SS #177 stated she reported the information to the director of nursing for her to investigate. When asked, she stated there had been no follow up communication between herself and the director of nursing. Interview on 05/11/12 at 1:10 P.M. with Director of Nursing (DON) #186 revealed she had not been informed prior to the annual survey of any abuse allegation by Resident #06. Record review of the facility self-reported incidents revealed no documentation of physical abuse investigation since 10/18/21. Record review of the facility's abuse policy dated 11/21/16 revealed all alleged violations involving abuse should be investigated and reported immediately to the Administrator and to the Ohio Department of Health. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 4 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 interview, observation, and record review, the facility failed to provide activity of daily living (ADL) care for one resident (#66) of five residents reviewed for ADL care. The facility census was 71. Residents Affected - Few Findings include Review of the medical record for the Resident #66 revealed an admission date of 03/18/22. Diagnoses included end stage renal disease, type two diabetes, anemia, opioid dependence, anxiety, heart failure, back pain, intervertebral disc degeneration, compression fracture, viral hepatitis, and chronic pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact and required limited assistance of one staff member for bed mobility, transfers and personal hygiene. Review of the plan of care dated 03/31/22 revealed Resident #66 may require assistance with activities of daily living (ADL's) and may be at risk of developing complications associated with decreased ADL self performance with interventions including diabetic nail care, and groom (nails, shave, hair) himself with total assist. The care plan revealed resident was at risk with past behaviors of non-compliance with refusing nails being trimmed with interventions to document educational attempts related to compliance, educate resident and family on the negative outcomes of non-compliance, notify physician of non-compliance. Review of the progress notes revealed no mention of staff offering to provide ADL care and resident refusing. Observation and interview on 05/10/22 at 12:20 P.M. with Resident #66 revealed nails long over 1/2 inch to 3/4 inch past the nailbed. Resident also had a beard that appeared untrimmed and over a month of growth. Resident revealed he has not had his nails trimmed or beard shaved or trimmed since his admission. Resident revealed he would like his nails trimmed and also revealed he did not have a beard prior to his admission and reported I am waiting for my family to bring in my razor and some nail clippers since the staff do not provide that care. Interview on 05/11/22 at 9:40 A.M. with State Tested Nursing Assistant (STNA) #123 revealed the podiatrist will trim toenails for residents with diabetes and STNA's are responsible for providing fingernail care and trimming and shaving resident facial care. Interview on 05/11/22 at 11:13 A.M. with STNA #182 confirmed resident had long finger nails and beard is long and un trimmed. STNA revealed typically aides will ask residents on shower days whether they would like hygiene care provided. STNA revealed she will check with resident and provide care this shift. Interview on 05/11/22 at 1:16 P.M. with Licensed Practical Nurse (LPN) #172 revealed Resident #66 had a history of refusals for care including nails, dialysis, and repositioning. LPN confirmed history of refusals and attempts from staff are not consistently documented in the medical record. LPN revealed staff only have two recording refusals for care with no reasoning submitted and no evidence that education was provided as per the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 5 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 Observations on 05/11/22 and 05/12/22 revealed resident nails remained long and his beard remained untrimmed. Administrator was updated and was unaware Resident's ADL care was not provided yesterday as requested and discussed. No documentation of attempts was also confirmed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 6 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 observation, interviews, record review and review of the facility policy, the facility failed to measure and document a new skin alteration. This affected one resident (#06) of four residents reviewed for wounds. The facility census was 71. Residents Affected - Few Findings include: Review of medical record for Resident #06 revealed admission date of 01/17/21 with diagnoses including paralytic syndrome, type 2 Diabetes Mellitus, dementia, schizoaffective disorders, adjustment disorder, depression, and anxiety. The resident remains at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact, required extensive one assist for bed mobility, total dependence for dressing, toileting,transfer and supervision for eating. Observation on 5/11/22 at 4:01 P.M. with Licensed Practical Nurse (LPN) #132 of Resident #06's dressing changed revealed an additional wound noted to her right lower leg. The wound was an approximately one-inch by one quarter inch, scabbed area. There was an unknown, uncovered treatment adhered to the area. Several reddened circle areas were also noted. Resident #06 unable to answer questions regarding the source of the area. Record review on 05/11/22 at 4:22 P.M. of the electronic charting for Resident #06 with LPN #132 revealed no wound documentation for right lower leg area and no treatment order. Record review of progress noted dated 05/11/22 at 7:12 P.M. for Resident #06 revealed documentation of new area of concern to right lower leg, the certified nurse practitioner was notified. A diagnosis and treatment were received. Interview on 05/12/22 at 10:10 A.M. with LPN #101 revealed she had been informed of the area to Resident #06's right lower leg by an unidentified state tested nursing assistant the early morning of 05/09/22 just prior to the end of her shift. She stated she did measure the area, however, did not document it and did not provide the measurements by the end of the survey. LPN #101 stated she did contact the facility physician to update and send a secure picture for a diagnosis. She verified she did not document the wound measurements, communication with the physician, enter the treatment order or report the wound to the oncoming nurse. A care plan for Resident #06 revealed she was at risk for alteration in skin integrity with interventions which included to complete a skin assessment per the facility policy and inspect the skin during routine care. Review of facility policy for skin assessment dated [DATE] revealed areas of skin alterations which develop subsequently to admission are conscientiously followed on a weekly basis, an assessment of the area is performed and recorded in the residents medical record; Factors placing the resident at risk for non-healing or delayed healing are assessed; interventions for treatment are implemented in accordance to the residents needs and the residents responses are monitored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 7 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide glasses to assist the residents vision in a timely manner. This affected one resident (#71) of four residents reviewed for hearing and vision. The facility census was 71. Residents Affected - Few Findings include: Review of the medical record for Resident #71 revealed an admission date of 04/13/22 with diagnoses including chronic obstructive pulmonary disease, type 2 Diabetes Mellitus, heart failure, and age related nuclear cataract bilateral. The resident remains in the facility. The annual Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact, required extensive one assist for bed mobility, dressing, and personal hygiene. Resident required extensive two person assist for total dependence for toileting, and transfers, and limited assist with eating. Review of care plan revealed individualized inability to focus on objects, adjust to light and dark changes related to impaired vision with intervention that included to encourage glasses to be worn as needed. Interview on 05/09/22 at 2:22 P.M. with Resident#71 revealed she had an eye appointment and needed new glasses. She believed it was two months ago and she had not heard anything since. Review of progress notes and the electronic chart for Resident#71 revealed no information regarding her glasses. Review of documentation provided by Activity Director#136 for Resident#71 revealed an eye appointment on 12/28/21 with a new prescription order. Interview on 05/10/22 at 12:32 P.M. with Activity Director#136 revealed she had contacted the eye care company for Resident#71 on previous occasions and was informed the glasses were on order. She further shared she had contacted them today and was informed the eye care company did not submit approval with Medicaid, and the glasses had not been ordered. She verified she did not document any attempts to contact the eye care company. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 8 of 9 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 365515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Respiratory and Nursing Center of Dayton 3421 Pinnacle Road Moraine, OH 45439 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 interview and record review, the facility failed to obtain weights as ordered for one resident (#42) of six residents reviewed for nutrition. The facility census was 71. Residents Affected - Few Findings include Review of the medical record for the Resident #42 revealed an admission date of 03/22/21. Diagnoses included diabetes type two, cerebral infarction, hemiplegia, osteomyelitis, metabolic encephalopathy, peripheral vascular disease, convulsions, kidney failure, muscle weakness, hallucinations, and a below the knee amputation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was not assessed for mobility and cognition, Discharge MDS dated [DATE] revealed cognition was not assessed and resident required extensive assistance from staff and was totally dependent for transfers. Review of Physician orders for 04/19/22 revealed an order for daily weights for 14 days. Review of weights and vitals dated 04/19/22 revealed a weight of 86.2 pounds (lbs). Review of weights dated 04/25/22 revealed a weight of 86.6 lbs. Review of weights dated 05/04/22 revealed a weight of 76.8 lbs. No other weights were recorded under weights and vitals section of the medical record. Review of the treatment administration record (TAR) revealed resident weights were not recording on 04/21/22, 04/22/22, 04/23/22, 04/24/22, and 04/26/22. Observation on 05/09/22 at 2:23 P.M. of Resident #42 revealed he appeared thin and frail and was on tube feeding. Interview on 05/11/22 at 9:40 A.M. with State Tested Nursing Assistant (STNA) #123 revealed STNAs take weights but do not have access to know if orders are placed for weekly or daily weights and rely on the nurse to inform them of these changes and orders. Interview on 05/11/22 at 11:17 A.M. with Dietician #117 revealed she was not aware of daily weights being ordered but revealed the staff do not always get ordered weights like they should and it was a known problem to her. Dietician revealed she was not following for daily weights and did not realizes they were not being done. Dietician revealed once resident had a weight loss of about 10 lbs, she spoke with the physician about increasing the tube feed rate. Interview on 05/12/22 at 2:40 P.M. with Dietician #117 confirmed staff did not document daily weight as ordered in either the TAR or the weights and vitals section. It was confirmed facility has no evidence the order was followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365515 If continuation sheet Page 9 of 9