Inspection·February 16, 2023

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 Based on observation, resident interview, and staff interview, the facility failed to assist a female resident with facial hair removal. This affected one (Resident #28) of two residents reviewed for Activities of Daily Living(ADLs) assistance. The facility's census was 57. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 05/29/19. Diagnoses included chronic obstructive pulmonary disease (COPD), heart disease and depression. Review of the Minimum Data Set (MDS) assessment revealed Resident #28 was cognitively intact. Resident #28 required assistance of one staff member with bathing and maintaining hygiene. Review of Resident #28's progress notes from 01/01/23 to 02/13/23 revealed no documentation Resident #28 was asked if she wanted her facial hair removed, nor was there documentation showing Resident #28 refused facial hair removal. Review of Resident #28's Plan of Care last updated 11/15/22 revealed Resident #28 required one-person assistance for personal hygiene care and bathing. Skin inspections were to be performed with shower days. Review of Resident #28's shower sheets from 1/19/23 to 2/13/23 revealed no indication of Resident #28 being asked to have her facial hair plucked or shaved. Observation on 2/13/23 at 1:01 P.M. revealed Resident #28 had approximately five 1.5 inch (in) white hairs on her chin, in which were easily noticeable. Resident #28 verified she gets a shower two times per week. Observation and interview on 02/14/23 at 2:38 P.M. revealed Resident #28 still had white hairs on her chin present. Resident #28 reported she would prefer staff pluck her facial hair. Registered Nurse (RN) #91 was present during the observation and verified Resident #28 had facial hair present. Observation on 2/15/23 at 10:24 A.M. revealed Resident #28 still had white hairs on her chin present. Interview on 02/15/23 at 12:15 P.M. with the Director of Nursing (DON) verified Resident #28 received two showers per week and during showers, aides were to perform skin inspections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 record review, observation, staff interview, and review of the facility policy, the facility failed conduct a thorough investigation to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. This affected one (Resident #308) of three residents reviewed for fall follow up. The facility's census was 57. Findings include: Medical record review of Resident #308 revealed an admission date of 01/26/23, with diagnoses including chronic obstructive pulmonary disease, bladder disorder, restless leg syndrome, anxiety, hypothyroidism, obesity, chronic embolism in lower extremity, type two diabetes with diabetic neuropathy, neuralgia and neuritis, anemia, cardiomegaly, depression, pain, history of Coronavirus 2019 (COVID-19), schizoaffective disorder, and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #308 was cognitively intact. Resident #308 had delusions and rejected care regularly. Resident #308 required supervision for bed mobility, transfers, toileting, and eating. Resident #308 had a fall in the last two to six months, prior to admission. No therapy services had been provided since admission. Review of the plan of care dated 02/01/23 revealed Resident #308 was at risk for falls related to deconditioning, gait, balance problems, and psychoactive drug use. Interventions included anticipate and meet resident's needs in a timely manner, be sure call light is within reach and encourage/cue/remind to use it for assistance as needed, encourage and invite resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, encourage room change to be closer to nurses station, ensure a safe environment with: even floors, free from spills and/or clutter, adequate, glare-free light, bed in low locked position, personal items within reach, ensure non-skid footwear when ambulating, follow facility fall protocol, monitor oxygen saturation and mental status, notify physician of acute changes, physical therapy evaluate and treat as ordered, send to emergency room as ordered, and urine analysis due to mental status change. Review of Resident #308's active physician orders for the month of February 2023 revealed an order dated 02/15/23 for Norco (pain medication) oral tablet 5-235 milligrams (mg), one tablet by mouth every six hours as needed (PRN) for pain. Further review revealed an order dated 02/16/23 for Haldol (antipsychotic medication) oral tablet, give one eight mg tablet three times a day for schizoaffective disorder. A urinalysis with culture sensitivity was ordered 02/14/23. On 02/13/23 an order was added to monitor Resident #308 for the following: tearfulness, agitation, sleeplessness, and refusal of oxygen and medication every shift. Review of the elopement risk assessment dated [DATE] revealed Resident #308 was not cognitively impaired, ambulated independently, and had no history of elopements. Resident #308 was considered at minimal risk for elopement. Review of the social service progress notes dated 01/31/23 at 3:19 P.M. revealed Resident #308 admitted to the facility from another facility. Resident #308 had a healthcare power of attorney (POA). The resident had episodes of refusing medication and refusing blood sugars to be drawn. Staff continue to encourage and educate the resident on the importance of medication and blood sugar monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 There were no plans for the resident to discharge due to health care needs. Level of Harm - Minimal harm or potential for actual harm Review of the facility incident and accident log dated 02/01/23 to 02/14/23 revealed on 02/14/23, Resident #308 was involved in an incident outdoors and sustained injuries. Residents Affected - Few Review of the late progress note dated 02/14/23 at 12:30 A.M. and recreated on 02/15/23 at 7:37 A.M. revealed Resident #308 was in her room resting in bed at midnight. Resident #308 left her room and went down the stairs. The Licensed Practical Nurse (LPN) and the aide went down the stairs looking for Resident #308. The resident was found attempting to leave the building. By the time the LPN got to the resident, she had fallen right in front of the back door. Resident #308 was assessed before bringing her back upstairs to her room. Resident #308 had a few abrasions/scratches that were charted. Resident #308 stated she was waiting on her ride to Tennessee. Resident #308 was more confused than usual. Resident #308 had no complaints of pain at the time. Resident #308 was assessed in her room, cleaned up and put back in bed. The Director of Nursing (DON) was called, along with the physician, and her POA. One-on-one (1:1) care was provided after the incident for the shift and the resident would be monitored. Review of the facility's pre-printed, three-paged Fall Incident Investigation (paper version) dated 02/14/23 at 12:30 A.M. completed by LPN #17, revealed Resident #308 was injured and first aid was provided. Vitals signs were obtained with a blood pressure reading of 146 systolic over 85 diastolic (146/85), temperature was 96.5 Fahrenheit (F), heart rate (p) of 108, and respirations (r) of 20. Additionally, off to the side of the document was a second set of vitals (without time documented) which recorded a blood pressure reading of 142/81, temperature of 96.7 F, p 98 and r 18. Further review revealed the physician was contacted, power of attorney (POA) was notified, and the location of the fall incident was noted to be in a hall on the first floor. Resident #308 was confused, disoriented, and had a change in mental status. LPN #17 documented the resident toileted herself and the last time the resident received care was 12:00 A.M. Further review of the fall investigation revealed a question if the environment was new or changed and the answer was no specially regarding sufficient lighting and accessible handrail. The fall investigation documented items marked as no problem included clothing, bed, noise, chair, and bathroom. Review of the Conclusion Section revealed the resident was in bed resting at midnight. The aide heard the resident go out the stairwell door and the alarm sounded. Staff went after the resident. The resident was found and assessed and brought back to her room. Resident #308 was cleaned up, bandaged, and put back to bed. The last section of the document identified immediate interventions of: Resident #308 was assessed before bringing her back to her room. Resident #308 denied pain at the time. The resident was brought back to her room and any abrasions and scratches were cleaned. After the resident was assessed, the DON, doctor, and POA were notified. The resident had 1:1 care the remainder of shift. The investigation did not contain documentation for wounds measurements, location of wounds, there was no documentation regarding a head-to-toe assessment, what solution was used to clean injured areas and what dressings were applied, blood sugar levels or range of motions evaluation. Additionally, the investigation did not contain documentation for a root cause analysis to determine the possible reason for the fall. Review of the late entry progress note effective 02/14/23 at 8:55 A.M. revealed Resident #308 refused to move rooms and refused a Wanderguard (a device worn in which activates a door alarm to alert staff if the individual wearing the device opened and/or exited a door). Review of the progress note dated 02/14/23 at 9:21 A.M. revealed Resident #308 had bruising and swelling to her lower lip/chin. The resident denied pain or discomfort. A new order was received to send the resident to the emergency room (ER) for evaluation and treatment. The POA was called and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 message was left to call the facility for an update on new orders. Resident #308 was transported to the ER. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes dated 02/14/23 at 3:12 P.M. revealed Resident #308 returned from the ER with no new orders. The physician was aware, and a new order for a urinalysis with culture and sensitivity due to altered mental status was received. The resident was moved to a room closer to the nurse's station. Residents Affected - Few Review of the progress note dated 02/15/23 at 10:30 A.M. revealed new orders to increase Resident #308's medication due to increased delusions. Review of the progress note dated 02/15/23 at 11:10 A.M. revealed Resident #308 complained of increased pain. The Medical Director (MD) was notified and a new order was received. Review of the hospital Discharge summary dated [DATE] revealed Resident #308 was sent to the hospital for evaluation related to a fall. Resident #308 complained of acute shoulder pain, acute hand pain, acute knee pain and neck pain. No fractures were identified and the resident returned to the facility on [DATE]. Review of the progress note dated 02/16/23 at 6:33 A.M. revealed Resident #308 stated she was still sore from the fall, but the pain medication was helping. Review of the elopement assessment dated [DATE] revealed Resident #308 was cognitively impaired and ambulated independently. The resident had no history of elopement at home or leaving prior facility without supervision. Resident #308 had not verbally expressed the desire to go home. Resident #308 has packed belongings or stayed near the exit door. Resident #308 has not wandered aimlessly nor have family or responsible party voiced concerns that would indicate the resident might have wandering tendencies or try to leave the facility. Resident #308 was considered at minimal risk for elopement. Interview on 02/15/23 at 11:17 A.M. Social Worker (SW) #204 stated Resident #308 scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, however SW #204 verified Resident #308 had cognitive issues. SW #204 verified the resident would tell others that she was married to a famous singer and they had a home in another state together. Interview on 02/15/23 at 11:33 A.M. with Activity Director #54 revealed Resident #308 preferred to remain in her room for activities. The resident was asked to participate and would often state she will next time but it was very rare she would leave her room. Resident #308 did not like groups at all. Activity Director #54 stated the resident believed she was married to a famous singer and conversations were nonsensical most of the time. Additionally, Activities Director #54 stated the resident was confused most of the time and staff must navigate the conversation to determine the true intent of the message. Interview on 02/16/22 at 8:31 A.M. with LPN #17 verified a progress note was entered late regarding the incident with Resident #308 on 02/15/23 at 7:37 A.M. because she was not sure what needed to be included in the note. LPN #17 verified she completed a risk management report in the electronic health record and filled out a paper form documenting the details of the fall involving Resident #308 on 02/14/23 at 12:30 A.M. LPN #17 verified she was working the night of the incident with Resident #308. LPN #17 stated the alarm was going off at the end of the hall where Resident #308 resided. LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 #17 stated the door had an alarm and when you push on the door long enough (approximately 15 seconds), the door would open. LPN #17 verified the alarm was not very loud. LPN #17 stated she was helping another resident at the front of the unit and off to the side so she did not see Resident #308 leave her room initially. The aide went one way, and she (LPN #17) went the other way on the stairs, as they did not have sight of Resident #308 and did not know which way she went. LPN #17 stated when she made it to the door, Resident #308 had already made it down the stairs to the first floor and was pushing on the exterior door at the landing setting off the alarm and had fallen. LPN #17 stated when she arrived, she observed the resident on the ground against the door. Resident #308 had abrasions on her knees, hands, and her chin and the exterior door alarm was sounding but she did not get out of the facility. LPN #17 stated she was unsure who actually set the alarm off because she was helping the resident and they were both leaning on the door. The door did pop open because it had the same type of alarm on it as the other door, when you push on it long enough it will open. LPN #17 stated at first, Resident #308 had a small scratch on her chin and there was no swelling. As time passed the swelling to her lower lip and chin worsened. LPN #17 called for another LPN to assist with assessment to make sure nothing was missed. LPN #17 stated the third floor LPN (#57) assisted her after Resident #308 was found on the ground. LPN #17 stated LPN #57 stayed with Resident #308 while she went to get the supplies to clean up Resident #308's abrasions. After LPN #17 and LPN #57 assessed Resident #308 for injuries, LPN #17 called the Nurse Practitioner (NP) on call and was advised to wait until they were able to get to the facility in the morning, and they would evaluate Resident #308 then. LPN #17 stated she monitored the resident with neuro checks and watched the swelling increase, but all her vital signs were normal. The dark discoloration and swelling on Resident #308's face just started worsening over time. LPN #17 stated she did not witness the resident fall and did not realize that she hit her head until the swelling occurred to her face and chin. LPN #17 stated they implemented 1:1 care because Resident #308 had never left her room before that night. LPN #17 stated the resident was waiting for a ride to go to Tennessee and was more confused than usual. Resident #308 denied pain at the time of the incident. Observation on 02/16/23 at 8:54 A.M. with the Director of Nursing (DON) revealed when the 2nd floor door to the stairwell was pushed to activate the alarm, the alarm 'beeped' but was not very loud. The DON verified the alarm only beeps at the door and is hard to hear from the nurse's station. The DON then opened the exterior door at the bottom of the stairwell to the outside and the alarm went off loudly. The DON stated Resident #308 fell at the threshold of the door. The DON stated the nurse from the second floor responded to the exterior door alarm when Resident #308 fell. Interview on 02/16/23 at 2:45 P.M. with NP #202 verified she assessed Resident #308 on 02/14/23 after the fall occurred and stated she did not have any more than usual cognitive loss. Resident #308 was sent to the hospital for evaluation and returned with no acute injuries. NP #202 verified she was not notified at the time of the fall, but the physician was notified. NP #202 stated Resident #308 reported she fell down a hill when asked how the fall occurred. During a phone interview with the Administrator on 02/16/23 from 2:50 P.M. to 3:30 P.M., Resident #308's fall investigation from a fall on 02/14/23 was requested. The Administrator refused to provide the fall investigation for Resident #308's fall which occurred on 02/14/23. However, after further discussion with the Administrator a fall investigation was provided but further review of the document revealed there was no documentation of a root cause analysis. Further review revealed no witness statements were provided to the surveyors for review to clarify medical record documentation and staff interview discrepancies. Review of the facility's incident and accident log indicated Resident #308's fall occurred outdoors. Review of the facility's paper fall investigation revealed the fall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 occurred in the hall. There were no witness statements and no documentation if the fall was witnessed by a staff member, or unwitnessed. There were no details related to observation of the incident by staff, the residents' statements at the time of the fall, the severity of the injuries, staff interviews related to incident, fall interventions in place at the time of the fall or potential faulty equipment. Additional information regarding the risk management document included in the facility's electronic health record completed at the time of the incident (as reported by LPN #17) was refused by the Administrator. The Administrator reported the investigation provided was all that was needed, and the risk management document was an internal quality assurance document, and she did not have to provide the document. The Administrator verified the fall investigation utilized by the facility did not use the word root cause analysis and was unable or unwilling to provide any additional information that a thorough fall investigation had been completed by the facility to determine the underlying cause of the fall and current plans for prevention. Review of the summary of investigation dated 02/14/23 and signed by the Administrator, DON, and on the signature line for the Medical Director was handwritten via telephone, was presented to the surveyors just prior to exit conference on 02/16/23 at 5:20 P.M., revealed a root cause analysis of Resident #308 stated she was going to Tennessee. Resident #308 stated she owns a home in Tennessee and was married to a famous singer who lives there. A medication review was completed and medication changes were noted in the resident's medication administration record. Resident #308 refused room move and the resident was sent to the ER to rule out injury. The Administrator was unable and/or unwilling to provide a rationale as to why the document was not provided when requested. Interview on 02/17/23 at 11:08 A.M. with Physician #203 stated she was notified of a fall on 02/14/23 involving Resident #308. Physician #203 stated she was told it was a witnessed fall and the fall location was on the side of the building in a stairwell landing in front of an exterior door. The Surveyor advised Physician #203 the facility had provided a document at exit conference in which identified Physician #203 had participated in a meeting about Resident #308 to determine a root cause analysis for the fall on dated 02/14/23. Further Physician #203 was the Surveyors had requested this information during the survey and was told it was a protected document and the facility did not have to provide the risk management investigation related to Resident #308. Physician #203 was advised the facility never collected any witness statements, and the Surveyors were unable to collaborate the events, as the documents provided were not consistent. Physician #203 verified she spoke with the DON regarding Resident #203's fall but was unaware of the document indicating a root cause analysis was completed. Physician #203 verified she did not have a copy of the document, and does not know what the document states. Physician #203 was unaware the facility document had a signature line on it for her signature and was unaware the facility completed and dated the physician participated via phone along with the DON and the Administrator on 02/14/23. Physician #203 verified Resident #308 had not moved to a room closer to the nurse's station due to the fact the resident refused. Physician #302 verified she completed a medication review for Resident #203 on 02/17/23 during her visit to the facility. A request for a policy related to the completion of incident investigations was requested during the survey and not provided for review. Review of the facility policy titled, Resident Falls, undated, revealed under the title of documentation, in the nurses notes, the facility will record a head to toe assessment of the resident, the position observed, and describe any injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide each resident or resident representatives with education regarding the risks and benefits of influenza immunizations on an annual basis, when influenza vaccines were offered. This affected three (Residents #10, #23 and #27) of five residents reviewed for immunizations. The facility census was 57. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #10 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus with other circulatory complications, atrial fibrillation, gastro esophageal reflux disease without esophagitis, major depressive disorder and hypertensive retinopathy. Review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting, transfers, and personal hygiene. Resident #10 required supervision with eating. Review of Resident #10's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the Director of Nursing (DON). Review of Resident #10's consent to administer influenza vaccine form dated 09/11/19 revealed Resident #10 wished to receive an annual influenza vaccine. There was no indication Resident #10 received or signed the influenza consent form on 09/11/19. Additionally, there were no other consent forms completed. 2. Medical record review revealed Resident #23 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, bradycardia, retention of urine, insomnia, constipation, major depressive disorder, schizophrenia, and bipolar disorder. Review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, dressing, and eating. Resident #23 also required total dependence with transfers, toileting, and personal hygiene. Review of Resident #23's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the DON. Review of Resident #23's consent to administer influenza vaccine form dated 09/19/19 revealed Resident #23 wished to receive an annual influenza vaccine. There was no indication Resident #23 nor the resident's representative received or signed an influenza consent on 09/19/19. Additionally, there were no other consent forms completed. 3. Medical record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, unspecified dementia, depression, insomnia, epilepsy, convulsion, cataract, glaucoma in diseases classified elsewhere, unspecified psychosis not due to a substance or known physiological condition, and disorientation. Review of Resident #27's quarterly MDS assessment dated [DATE] revealed the resident was moderately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 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 365716 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 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 0883 Level of Harm - Minimal harm or potential for actual harm cognitively impaired and required supervision with bed mobility, dressing, toileting, transfers, eating and personal hygiene. Review of Resident #27's immunization record revealed on 10/10/22, the resident was administered the influenza vaccine by the DON. Residents Affected - Few Review of Resident #27's consent to administer influenza vaccine form dated 09/19/19 revealed Resident #27 wished to receive an annual influenza vaccine. There was no indication Resident #27 nor the resident's representative received or signed an influenza consent on 09/19/19. Additionally, there were no other consent forms completed. Interview on 02/14/23 at 10:37 A.M. with the DON verified Residents #10, #23, and #27 did not have updated influenza consents since 2019, and Residents #10, #23, and #27 were administered influenza vaccines on 10/10/22. Review of the facility's flu and pneumococcal vaccine policy dated 08/09/19 revealed all residents of the facility will be offered the flu vaccine on admission and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365716 If continuation sheet Page 9 of 9