Health inspection·August 9, 2018

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review, the facility failed to ensure curtains and doors were closed for privacy for Resident #16 and #39. Additionally, the facility failed to protect private information for Resident #40. This affected three (#16, #39, and #40) of 24 residents reviewed for personal privacy during the annual survey. The facility census was 80. Residents Affected - Few Findings include: 1. Medical record review for Resident #16 revealed an admission date of 05/21/18. Diagnoses included heart failure. Review of Minimum Data Set (MDS) assessment, dated 05/28/18, revealed the resident was rarely or never understood. Observation of medication administration for Resident #16 on 08/08/18 at 11:22 A.M. revealed Licensed Practical Nurse (LPN) #37 went into the room and pulled the covers down and exposed the resident with her gown up over her brief to the hallway and roommate. Interview with LPN #37 on 08/08/18 at 11:24 A.M. verified she should have pulled the curtain and shut the door for privacy. Review of the admission packet entitled Privacy and Confidentiality revealed the resident has the right to personal privacy. 2. Medical record review for the Resident #40 revealed an admission date of 09/20/17. Diagnoses included aphasia and cerebrovascular accident. Review of MDS assessment, dated 07/03/18, revealed Resident #40 was rarely or never understood. Interview on 08/07/18 at 4:00 P.M. with State Test Nursing Aide (STNA) #43 for activities revealed she left her 1:1 documentation book for the residents either at home or in her car. She stated she would go to her car and look for it. When asked if she was allowed to take personal information about the residents out of the facility, she replied 'no'. A subsequent interview was conducted at 4:31 P.M. revealed STNA #43 verified she left her 1:1 visits book in her car. Review of the admission packet entitled Privacy and Confidentiality revealed the facility must respect the resident's right to personal privacy, including the right to privacy in his or her oral, written and electronic communications. 3. Review of medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, cerebral infarction, aphasia, and epilepsy. Review of the MDS assessment, dated 07/03/18, revealed Resident #39 required total assistance with bed mobility, toileting, eating, and is totally dependent with personal hygiene, dressing, transfer, and bathing. On 08/07/18 at 9:15 A.M., observation of State Tested Nursing Assistant (STNA) #48 entered Resident #39's room and pulled her bed sheet down exposing unclothed lower body. Resident #39 was wearing an incontinent brief. STNA #48 looked at the brief and then left the room. Resident #39 remained uncovered as STNA #48 left without closing door or pulling privacy curtain around resident. Roommate of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 2 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0583 Level of Harm - Minimal harm or potential for actual harm Resident #39 was present in room, lying in bed on other side of privacy curtain. The resident was exposed to the hallway. Interview on 08/07/18 at 9:41 A.M. with STNA #48, verified the privacy curtain was not pulled around the resident in her room and the door to the hallway was left open exposing the unclothed resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 3 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of facility policy, and record review, the facility failed to implement their abuse policy for an allegation of verbal abuse. This affected one (#41) of one resident reviewed for abuse. The facility census was 80. Residents Affected - Few Findings include: Review of medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracranial hemorrhage, generalized anxiety disorder, Parkinson's disease, and dementia with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment, dated 07/03/18, revealed Resident #41 required extensive assistance with bed mobility, toileting, eating, personal hygiene and transfers. Resident #41 requires limited assistance for ambulation and had severe cognitive impairment. Review of the resident's medical record revealed there was no evidence of an incident with the resident and a staff member. Interview with Resident #41 on 08/06/18 at 3:19 P.M. revealed the resident identified and verbally responded appropriately to name being called. Resident #41 was ambulating independently in room with assistive device. Resident #41 alleged the night before (08/05/18) a state tested nursing assistant (STNA) entered his room at 11:00 P.M., STNA stated she did not have to take care of a person with Parkinson's disease. STNA removed the call light from his bed and threw it on the floor. Resident #41 further revealed the incident was witnessed by the 'head nurse'. He stated the STNA was assigned to another room. Interview with Licensed Practical Nurse (LPN) #165 on 08/07/18 at 5:00 P.M., revealed the alleged abuse was not reported to her. LPN #165 did not witness any verbal abuse by staff on 08/05/18 on the 3-11 shift. Interview with STNA #15 on 08/07/18 at 2:07 P.M. revealed there were no behaviors or allegations of abuse on 08/05/17 from the 11:00 P.M. to 7:00 A.M. shift. Interview with Administrator on 08/07/18 at 1:30 P.M. advising her Resident #41 had made an allegation of verbal abuse from staff. Advised Administrator of ongoing interviews with staff members. Administrator had questions related to the reporting process and requested clarification of self-reporting when video documentation verified that allegation did not occurred. Interview with Administrator on 08/08/18 at 3:00 P.M. verified a self-reported incident with the Ohio Department of Health had not be filed. Administrator stated report was not filed because investigation by Ohio Department of Health had not revealed any evidence the allegation had occurred. Administrator verified that the facility did not investigate the alleged abuse. Review of the facility's self-reported incidents revealed a verbal abuse allegation involving Resident #41 was not reported to the state agency, Ohio Department of Health. Review of undated facility policy on abuse, neglect and/or misappropriation of resident property revealed the facility did not follow the policy and investigate the abuse allegation. The policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 4 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0607 Level of Harm - Minimal harm or potential for actual harm stated under investigation, when the facility becomes aware of the allegation of abuse, neglect or misappropriation, it will be immediately reported to the Ohio Department of Health as mandated by Ohio law. The facility must then conduct a thorough investigation. The results of the investigation will be reported to the Administrator, the Ohio Department of Health and other state officials as mandated by state law within five working days of the incident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 5 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of facility policy, and record review, the facility failed to report an allegation of verbal abuse to the state agency, Ohio Department of Health. This affected one (#41) of one resident reviewed for abuse. The facility census was 80. Findings include: Review of medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracranial hemorrhage, generalized anxiety disorder, Parkinson's disease, and dementia with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment, dated 07/03/18, revealed Resident #41 required extensive assistance with bed mobility, toileting, eating, personal hygiene and transfers. Resident #41 requires limited assistance for ambulation and had severe cognitive impairment. Review of the resident's medical record revealed there was no evidence of an incident with the resident and a staff member. Interview with Resident #41 on 08/06/18 at 3:19 P.M. revealed the resident identified and verbally responded appropriately to name being called. Resident #41 was ambulating independently in room with assistive device. Resident #41 alleged the night before (08/05/18) a state tested nursing assistant (STNA) entered his room at 11:00 P.M., STNA stated she did not have to take care of a person with Parkinson's disease. STNA removed the call light from his bed and threw it on the floor. Resident #41 further revealed the incident was witnessed by the 'head nurse'. He stated the STNA was assigned to another room. Interview with Licensed Practical Nurse (LPN) #165 on 08/07/18 at 5:00 P.M., revealed the alleged abuse was not reported to her. LPN #165 did not witness any verbal abuse by staff on 08/05/18 on the 3-11 shift. Interview with STNA #15 on 08/07/18 at 2:07 P.M. revealed there were no behaviors or allegations of abuse on 08/05/17 from the 11:00 P.M. to 7:00 A.M. shift. Interview with Administrator on 08/07/18 at 1:30 P.M. advising her Resident #41 had made an allegation of verbal abuse from staff. Advised Administrator of ongoing interviews with staff members. Administrator had questions related to the reporting process and requested clarification of self-reporting when video documentation verified that allegation did not occurred. Interview with Administrator on 08/08/18 at 3:00 P.M. verified a self-reported incident with the Ohio Department of Health had not be filed. Administrator stated report was not filed because investigation by Ohio Department of Health had not revealed any evidence the allegation had occurred. Administrator verified that the facility did not investigate the alleged abuse. Review of the facility's self-reported incidents revealed a verbal abuse allegation involving Resident #41 was not reported to the state agency, Ohio Department of Health. Review of undated facility policy on abuse, neglect and/or misappropriation of resident property (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 6 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete revealed the facility did not follow the policy and investigate the abuse allegation. The policy, stated under investigation, when the facility becomes aware of the allegation of abuse, neglect or misappropriation, it will be immediately reported to the Ohio Department of Health as mandated by Ohio law. The facility must then conduct a thorough investigation. The results of the investigation will be reported to the Administrator, the Ohio Department of Health and other state officials as mandated by state law within five working days of the incident. Event ID: Facility ID: 365716 If continuation sheet Page 7 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 observation, resident and staff interview, review of facility policy, and record review, the facility failed to investigate an allegation of verbal abuse. This affected one (#41) of one resident reviewed for abuse. The facility census was 80. Residents Affected - Few Findings include: Review of medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included nontraumatic intracranial hemorrhage, generalized anxiety disorder, Parkinson's disease, and dementia with Lewy bodies. Review of the admission Minimum Data Set (MDS) assessment, dated 07/03/18, revealed Resident #41 required extensive assistance with bed mobility, toileting, eating, personal hygiene and transfers. Resident #41 requires limited assistance for ambulation and had severe cognitive impairment. Review of the resident's medical record revealed there was no evidence of an incident with the resident and a staff member. Interview with Resident #41 on 08/06/18 at 3:19 P.M. revealed the resident identified and verbally responded appropriately to name being called. Resident #41 was ambulating independently in room with assistive device. Resident #41 alleged the night before (08/05/18) a state tested nursing assistant (STNA) entered his room at 11:00 P.M., STNA stated she did not have to take care of a person with Parkinson's disease. STNA removed the call light from his bed and threw it on the floor. Resident #41 further revealed the incident was witnessed by the 'head nurse'. He stated the STNA was assigned to another room. Interview with Licensed Practical Nurse (LPN) #165 on 08/07/18 at 5:00 P.M., revealed the alleged abuse was not reported to her. LPN #165 did not witness any verbal abuse by staff on 08/05/18 on the 3-11 shift. Interview with STNA #15 on 08/07/18 at 2:07 P.M. revealed there were no behaviors or allegations of abuse on 08/05/18 from the 11:00 P.M. to 7:00 A.M. shift. Interview with Administrator on 08/07/18 at 1:30 P.M. advising her Resident #41 had made an allegation of verbal abuse from staff. Advised Administrator of ongoing interviews with staff members. Administrator had questions related to the reporting process and requested clarification of self-reporting when video documentation verified that allegation did not occurred. Interview with Administrator on 08/08/18 at 3:00 P.M. verified a self-reported incident with the Ohio Department of Health had not be filed. Administrator stated report was not filed because investigation by Ohio Department of Health had not revealed any evidence the allegation had occurred. Administrator verified that the facility did not investigate the alleged abuse. Review of the facility's self-reported incidents revealed a verbal abuse allegation involving Resident #41 was not reported to the state agency, Ohio Department of Health. Review of undated facility policy on abuse, neglect and/or misappropriation of resident property revealed the facility did not follow the policy and investigate the abuse allegation. The policy, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 8 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 Level of Harm - Minimal harm or potential for actual harm stated under investigation, when the facility becomes aware of the allegation of abuse, neglect or misappropriation, it will be immediately reported to the Ohio Department of Health as mandated by Ohio law. The facility must then conduct a thorough investigation. The results of the investigation will be reported to the Administrator, the Ohio Department of Health and other state officials as mandated by state law within five working days of the incident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 9 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 record review, staff interview and resident interview, the facility failed to develop and implement a baseline plan of care and provide a summary to the resident within 48 hours. This affected one (#342) of one resident reviewed for a baseline care plan. The facility census was 80. Findings include: Record review revealed Resident #342 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, history of deep venous thrombosis, hyperlipidemia, acute upper respiratory infection, gastroesophageal reflux disease, major depressive disorder, dizziness and giddiness, and hypertensive heart disease. Review of the resident's nurses notes revealed they were silent for documentation the resident or resident representative were provided a written baseline care plan. The nurse's note, dated 08/02/18 at 7:50 A.M., indicated Resident #342 was alert and oriented to person, place and time. Review of care plan section located in paper chart for Resident #342 revealed a plan of care for falls and an immediate need care plan that had the resident's name on them but were not completed, dated or signed by a staff member. Review of care plan tab in the electronic health care record (EHR) for Resident #342 on 08/06/18 at 5:15 P.M., revealed a care plan, dated 08/02/1,8 had been initiated but the document was blank at that time. Interview with Resident #342 on 08/08/18 at 4:47 P.M., revealed the resident was not provided with any documentation related to treatment goals and care plans related to current stay at this facility. Interview with Licensed Practical Nurse #29 on 08/08/18 at 4:28 P.M. verified the documents located in paper chart under care plan tab labeled immediate need care plan and document labeled plan of care for falls were not completed, dated or signed at this time. On 08/09/18 at 9:33 A.M., interview with Registered Nurse #84 provided a blank copy of documents labeled admission Evaluation/Interim Care plan. This could be located in the assessment tab in the resident's electronic health record. Further indicating that he/she was currently developing a baseline plan of care in the EHR and the facility does not have a policy or procedure for the 48-hour baseline care plan completion process. Interview with Director of Nursing 08/08/18 04:30 P.M. revealed she could not verify the document was provided to Resident #342. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 10 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and review of facility's admission packet, the facility failed to ensure Resident #50 was able to go to activities. This affected one (#50) of six residents reviewed for activities during the annual survey. The facility census was 80. Residents Affected - Few Findings include: Medical record review for Resident #50 revealed an admission dated of 12/23/15. Diagnoses included human immunodeficiency virus and acute transverse myelitis in demyelinating disease of central nervous system. Review of the annual Minimum Data Set (MDS) assessment, dated 04/09/18, revealed the resident felt it was very important to do do things with groups of people. Review of the quarterly MDS, dated [DATE], revealed the resident was cognitively impaired and the resident was an extensive assistance for bed mobility, totally dependent on staff for transfer and the resident did not ambulate. Review of care plan for Resident #50 revealed staff will remind and invite the resident to all scheduled activities and honor her choice to pursue the activities. Review of activity participation record for Resident #50 revealed it was documented the resident was in bed on 08/06/18 for the first activity of the day, which was 9:30 A.M. and on 08/07/18, it was documented she was in bed for the first activity at 9:30 A.M. and second activity at 10:00 A.M. of the day. Observation of call light for Resident #50 on 08/07/18 at 8:40 A.M. revealed the resident called out and Licensed Practical Nurse (LPN) #49 answered the call light and turned it off. Observation on 08/07/18 between 8:40 A.M. to 9:50 A.M. of Resident #50 revealed she was lying in bed waiting to get up for the day. Interview with Resident #50 on 08/07/18 at 8:45 A.M. stated she asked to get out of bed for the day at 6:00 A.M. and at 8:40 A.M. when she rang the call light. She was tearful and stated she wanted to leave the facility, because she had to wait to get out of bed and therefore missed activities that were important to her. She stated she had told all the aides she wanted to get out of bed before the activities started at 9:30 A.M. Interview with State Tested Nursing Aide (STNA) #5 on 08/07/18 at 9:56 A.M. revealed she received in report Resident #50 asked at 6:00 A.M. to get out of bed, but the aide thought the resident was confused and didn't get her up. STNA #5 stated the resident told her, when she came on duty, she asked to get out of bed at 6:00 A.M. but no one got her up for the day. The STNA verified she did not get the resident out of bed when the resident told her this. Interview with LPN #49 on 08/07/18 at 11:49 A.M. revealed she told STNA #5 she wanted to get out of bed for the day. Interview with Activity STNA #23 on 08/07/18 at 4:00 P.M. revealed the resident didn't come to activities on 08/06/18 or 08/07/18 for the morning activities and stated it was rare. Review of the undated activities and recreation portion from the admission packet revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 11 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 facility offered a wide variety of opportunities to maximize the resident's creative self-expression, personal growth and enrichment, physical activity and social enjoyment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 12 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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, staff interview and medical record review, the facility failed to utilize therapy recommended hand and elbow splints devices. This affected one (Resident #39) of one resident reviewed for contractures during the annual survey. The facility census was 80. Findings include: Review of medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, cerebral infarction, aphasia, and epilepsy. Review of Minimum Data Set (MDS) assessment, dated 07/03/18, revealed the resident required total assistance with bed mobility, toileting, and eating and the resident had functional impairments to left upper and lower extremities. Review of the physician's signed orders, dated 04/27/18, revealed Resident #39 was to wear left elbow extension splint and left resting hand splint for eight hours throughout the day. Review of facility's state tested nursing assistant (STNA) documentation binder for the month of August 2018 revealed the undated document labeled Total Plan of Patient Care indicated Resident #39 was to wear an elbow extension splint for eight hours during the day. This binder revealed the splinting referral form, dated 04/16/18 and signed by Occupational Therapist (OT) #151, provided instructions to include, where the splint was to be placed (left hand), the purpose of the splint (prevent contractures), directions for length of time, when to wear splint (on during the day and off at night), and before and after care of extremity after splint was removed. Observation conducted on Resident #39 at 08/07/18 at 9:15 A.M., and 08/08/18 at 9:48 A.M. revealed Resident #39 had impaired mobility of left wrist and elbow with no use of recommended splinting devices observed. Interview on 08/08/18 at 10:18 A.M. with OT #151 stated Resident #39 was admitted to the facility with limited function of left elbow, left wrist and left hand. OT #151 stated Resident #39 was referred to occupational therapy (OT) for contracture management of left upper extremity to prevent skin breakdown, improve joint integrity and to reduce pain from 03/14/18 thru 4/27/18 and again on 06/18/18 thru 07/17/18. OT #151 stated when Resident #39 was discharged from OT services on 04/27/18, therapy recommendations for Resident #39 was to wear left elbow extension splint and left resting hand splint for eight hours throughout the day. Interview on 08/08/18 at 10:36 A.M. with STNA #48 verified Resident #39 was not wearing any splinting devices on 08/06/18, 08/07/18 or 08/08/18 during the day shift. STNA #48 was unaware of how long Resident #39 has been without them. Interview on 08/08/18 at 11:05 A.M. with Licensed Practical Nurse #29 verified there were no orders written for Resident #39 for the month of August 2018 to apply splints for a specific time frame. Interview on 08/09/18 at 10:18 A.M. with OT #151 stated the therapy referral that was recommended on 04/16/18 was still in place and there was not any change to the time frames or splinting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 13 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 appliances at the discontinuation of the last therapy certification period ending last month (July 2018). Subsequent interview conducted on 08/08/18 at 12:05 P.M. stated the wrist had a three percent decrease in passive range of motion (PROM) when compared to the initial assessment at the beginning of the resident's treatment but was still within the normal functional range of motion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 14 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure each resident received adequate supervision with eating for a resident at risk for choking and aspiration pneumonia. This affected one (Resident #28) of one resident reviewed for nutrition. The facility census was 80. Findings include: Record review revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition, hyperlipidemia, heart failure and chronic kidney disease. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had cognitive impairments and required extensive assistance (resident able to perform part of the activity and assisted by staff to complete task) of one staff member for eating. Review of the speech therapist's dysphagia guidelines, dated 07/02/18 for Resident #28, stated the resident's current diet was nectar thickened liquids, mechanical soft and carbonated thin liquids. It was noted the resident had a history of aspiration, dysphagia (difficulty chewing food), malnutrition/dehydration and weight loss. Resident #28 was at risk for choking, aspiration pneumonia, malnutrition/dehydration and weight loss. The resident's behaviors included limited attention to task, reduced cognition, prolonged mastication (chewing of food), decreased safety awareness and discontinuation of fluid restrictions. Speech therapy recommendation for meal times was one to one feeding assistant at meals, small sips and bites, alternate bites and sips, neutral head position, and sitting upright at a 90 degree angling chair or bed. Observations of Resident #28 on 08/06/18 at 12:05 P.M. and 08/09/18 at 11:44 A.M., revealed he was eating in his room without supervision or assistance from staff. Interview with State Tested Nursing Assistant (STNA) #159 on 08/09/18 at 2:49 P.M. stated Resident #28 does not want to eat in the dining room per his choice. The STNA stated Resident #28 only required set up assistance for meals at this time and verified the staff does not stay in the room while he consumes meal. Interview with Licensed Practical Nurse (LPN) #21 on 08/09/18 at 2:45 P.M. verified staff does not sit with him for meal consumption. Interview with STNA #48 on 08/09/18 at 2:53 P.M. verified staff just sets his meal up (open containers and packages) and verified staff do not provide one on one feeding assistance. Interview with LPN # 29 on 08/09/18 at 2:50 P.M. verified Resident #28 chooses to eat all meals in his/her room and stated the majority of the time he will eat in his room unsupervised. Interview with STNA #159 on 08/09/18 at 2:49 P.M. verified the resident does not receive assistance while eating meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 15 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure insulin was discarded 28 days after being opened. This affected five (Resident #3, #4, #24, #57 and #60) of 14 residents who received insulin. The facility census was 80. Findings include: 1. Observation on [DATE] at 8:15 A.M. with Licensed Practical Nurse (LPN) #29's of the medication cart on her assignment revealed Resident #3's Lantus was dated [DATE], Resident #4's Novolog was dated [DATE] and Levemir was dated [DATE], and Resident #57's Levemir was dated [DATE] and Novolog was dated [DATE]. Interview with LPN #29 on [DATE] at 8:20 A.M. verified the above mentioned insulin's should have been discarded within 28 days of opening date on the vials. 2. Observation was conducted on [DATE] at 8:25 A.M. of LPN's #37's medication cart revealed Resident #60's Humalog was dated [DATE] and Resident #24's Novolog was dated [DATE]. Interview with LPN #37 on [DATE] at 8:30 A.M. verified the above mentioned insulin's should have been discarded within 28 days of opening date on the vials. Review of facility's undated policy and procedure entitled Medication Administration Policy revealed nursing personnel will ensure safe and effective administration of medication as prescribed by a physician in a timely manner and verify the medication was not expired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 16 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 staff interview and review of infection logs, the facility failed to establish and implement an infection control plan that used evidence based surveillance criteria to define infections, identify organisms and the use of a data collection tool. This had the potential to affect all 80 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility infection control log for the months of January 2018 through August 2018 revealed entries with missing site, culture, and organism information related to antibiotic use. Interview on 08/09/18 at 11:06 A.M. with the Director of Nursing (DON) revealed she had no knowledge of the facility using any type of evidence-based surveillance criteria such as McGreer Criteria to define infections and verified the infection control log did not reveal the site of the infections, the organisms or cultures for antibiotic usage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 17 of 18 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, infection control log review and policy review, the facility failed to maintain an antibiotic stewardship program with processes for periodic review of antibiotic usage and antibiotic use monitoring. This had the potential to affect all 80 residents residing in the facility. Residents Affected - Many Findings include: Review of the infection control log with the Director of Nursing (DON) on 08/09/18 at 11:06 A.M. revealed monthly tracking and trending of infections for residents for the months January 2018 through August 2018 revealed residents infections were logged without cultures and organisms documented. The DON verified the infection control log was missing these components. Interview on 08/09/18 at 11:06 A.M. with the Director of Nursing (DON) who stated she received a monthly report from the pharmacy that shows the antibiotic days of therapy per resident. The DON revealed the report shows the resident's name, the antibiotic, the dispense date of the antibiotic, the start date, quantity and days of therapy. The DON stated she was planning on utilizing the report to talk to the medical director about the number of antibiotics that were prescribed without cultures and organisms. The DON stated she was concerned about the number of antibiotics being prescribed. Review of the facility policy titled Mission Statement for Antibiotic Stewardship revealed facility management will develop, use and monitor facility specific algorithms to assess, test, prescribe and monitor infections and antibiotic use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 18 of 18