Health inspection·February 10, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure the comprehensive care plan addressed non-invasive mechanical ventilator use for two (Resident #69 and Resident #93) of three sampled residents reviewed for respiratory care. Findings include:1. Medical record review revealed Resident #69 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive sleep apnea. The Order Summary Report with active orders as of 01/30/26, revealed an order dated 10/21/25, for auto bilevel positive airway pressure (BiPAP) (a non-invasive mechanical ventilator) every night at bedtime and as needed throughout the day during sleep. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #69 had moderately impaired cognitive skills for daily decision-making. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Resident #69's comprehensive Care Plan Report with an admission date of 07/18/25 revealed the care plan did not address the resident's use of a BiPAP machine. During observations on 01/27/26 at 9:55 A.M. and 01/29/26 at 3:55 P.M., Resident #69 had a BiPAP machine in their room. During an interview on 01/30/26 at 10:33 A.M., MDS Nurse #500 stated she was responsible for a resident's nursing care plans. MDS Nurse #500 reviewed Resident #69's comprehensive care plan report and confirmed the resident did not have a care plan for the use of the BiPAP machine. The MDS Nurse stated Resident #69 should have a care plan and it was important so that staff knew the resident had a BiPAP. During an interview on 01/30/26 at 1:34 P.M., the Director of Nursing stated she expected the BiPAP to be addressed on a resident's comprehensive care plan. During an interview on 01/30/26 at 2:39 P.M., the Administrator stated each department completed their own section of the comprehensive care plan, then the MDS Nurse would ensure the care plan was completed. The Administrator stated she expected the BiPAP machine to be addressed on the comprehensive care plan for Resident #69. 2. Medical record review revealed Resident #93 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and obstructive sleep apnea. Page 1 of 2 365716 365716 02/10/2026 Grafton Oaks Nursing Center 405 Grafton Avenue Dayton, OH 45406

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Order Summary Report revealed an order dated 08/21/25, for Resident #93 was to wear the Bilevel Positive Airway Pressure (BiPAP) (a noninvasive mechanical ventilator) at night at bedtime for sleep apnea. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident used a non-invasive mechanical ventilator during the last 14 days of the assessment period. Review of Resident #93's comprehensive Care Plan Report with an admission date of 08/20/25 revealed the care plan did not address the resident's use of a BiPAP machine. During an interview on 01/30/26 at 1:26 P.M., the MDS Nurse #500 acknowledged Resident #93's care plan did not have any interventions related to the resident's use of the BiPaP machine. A facility policy titled Comprehensive Care Plans, revised 01/10/25, revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. This deficiency represents non-compliance investigated under Complaint Number 2627520. 365716 Page 2 of 2