Health inspection·May 24, 2023

F 0600 Level of Harm - Actual harm Residents Affected - Few Review of the medical record for Resident #06 revealed an admission date of 06/02/22. Diagnoses included schizoaffective disorder, chronic obstructive pulmonary disease (COPD), diabetes, anxiety, bipolar disorder, insomnia, abnormal weight loss, and heart disease. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #06 was cognitively impaired and required assistance for activities of daily living. Review of the progress notes dated 05/04/23 revealed Resident #06 was sitting in a wheelchair in her room and was struck in the face by Resident #59. The Nurse Practitioner (#127) heard the resident yelling and informed the nurse of the altercation. Resident #59, the suspected perpetrator, informed staff that he was not putting up with that and hit her. Resident #06 reported she was struck in the face with closed fists on both sides of her face. Review of the SRI dated 05/04/23 revealed Resident #06 reported Resident #59 came into her room and struck her in the face when attempting to get Resident #59 out of her bed. Staff removed Resident #59 from Resident #06's bed, assessed both residents and contacted all necessary parties. Residents were assessed with no known injuries. The investigation included statements: Nurse Practitioner (NP) #127 reported she was in her office and heard Resident #06 yell out and said Resident #59 was in her room and he had hit her. NP #127 went to Resident #06's room and found Resident #59 exiting the room. When asked what happened Resident #59 stated he hit that expletive. Resident #59 was wheeled back to his room. Interview on 05/24/23 at 12:15 P.M. with NP #127 revealed her office was across the hall from Resident #06's room. NP #127 revealed she heard Resident #06 yell he hit me. NP #127 said she arrived at Resident #06's room as Resident #59 was exiting the room and she asked Resident #59 if he hit Resident #06, and he responded, yes, he hit that expletive. She deserved it. NP #127 revealed she spoke with Resident #06 who reported Resident #59 struck her on the left side of her cheek with a closed fist and reported she could see a red mark. NP #127 stated she spoke with Resident #06 daily for a few days after the incident and reported Resident #06 stated, he doesn't belong here, and he isn't like us. NP #127 revealed she had talked with the facility staff about his history of behaviors and aggression with other residents and had discussed with staff he was not appropriate for this facility as they have not been able to manage his behaviors and revealed she thought Resident #59 had Lewy body dementia. NP #127 revealed Resident #59 was placed on 1:1 after the incident and had several medication changes including a genetic test to determine which psychiatric medications were working for him. NP #127 reported his behavior had improved in the last few weeks and stated if resident did have Lewy bodies the facility was not capable of caring for him. She revealed he had flipped a table since then and had aggression more generally and directed at staff. NP #127 revealed being unaware why the referral process ended related to his transfer discussed in 03/2023 and reported behaviors have not changed much since that time. Interview on 05/24/23 at 10:02 A.M. with the Social Services #65 and the Director of Nursing (DON) confirmed a care conference meeting was held 03/2023 and the interdisciplinary team discussed Resident #59's behaviors and it was reported that the facility was unable to manage Resident #59's behavior and aggression and he needed to transfer to another facility. Social Services #65 revealed the facility sent about three referrals to their sister facilities but revealed Resident #59 had not been accepted. Social Services #65 and the DON denied neither Residents #06 or #59 were moved off the unit or had room changes. Interview on 05/24/23 at 10:24 A.M. with Resident #06 revealed Resident #59 punched her in the face (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 2 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0600 about three weeks ago. Resident #06 said she feared Resident #59 and his behavior and did not feel safe at the facility. Level of Harm - Actual harm Residents Affected - Few Interview on 05/24/23 at 3:44 P.M., with the DON and Corporate Nurse #130 revealed a referral was sent to behavioral hospitals for admission and resident had a neurology appointment scheduled to review medications for appropriate effect. Resident #59 was placed on 1:1 supervision, but the DON reported 1:1 supervision was ordered on 05/08/23 to 05/18/23 and facility had no evidence of the 1:1 being in place consistently from 05/04/23 when the incident occurred until 05/08/23 when it was ordered. Corporate Nurse #130 and the DON revealed Social Services #65 would check on resident to provide support and revealed the facility had no evidence of psychosocial supports put in place after the incident on 05/04/23 except one check-in by social services asking how her day was going. 2. Review of the medical record for Resident #44 revealed an admission date of 06/21/22. Diagnoses included dementia with behavioral disturbances, hypertension, generalized anxiety disorder and dysphagia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #44 was cognitively impaired and required extensive assistance for all activities of daily living and supervision with eating. Review of the progress notes dated 03/19/23 revealed Resident #44 was standing at the nurse's station when another resident came up and struck her in the chest. Resident #44 was found to have no injuries. Review of the SRI dated 03/19/23 revealed Resident #44 was struck in the chest at the nurse's station by Resident #59. No injuries were noted. The investigation included statements: Certified Nurse Aide (CNA) #87 reported Resident #59 stood up from his chair and the CNA assisted him to sit back in his wheelchair which irritated Resident #59. CNA reported Resident #59 swung at her and missed and ended up hitting Resident #44. CNA #31 reported Resident #59 was at the nursing station and hit Resident #44 in the chest for no reason. CNA #88 revealed staff attempted to get Resident #59 to sit back in his wheelchair. Resident #59 became upset and started being aggressive and swinging at staff and ended up hitting Resident #44 in the chest who was standing at the nurses' station. Interview on 05/24/23 at 2:53 P.M. with CNA #88 revealed being at the nurses' station with Resident #44 who was exit seeking and Resident #59 was in his wheelchair and was having aggression and swinging his arms in the air. Resident #44 walked by Resident #59 and was struck in the chest. CNA #88 revealed Resident #44 did not have any injuries but was crying. 3. Review of the medical record for Resident #56 revealed an admission date of 05/12/20. Diagnoses included Alzheimer's disease, major depressive disorder, anxiety disorder, asthma, and abnormal weight loss. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #56 was cognitively impaired and required extensive assistance for all activities of daily living. Review of the progress notes dated 04/21/23 revealed staff were at the nurses' station when they heard screams coming from the 200 hall. Staff entered Resident #56's room and saw the over bed table lying on the floor in front of Resident #59 and Resident #56 was crying and had a trash bin placed on her head. Resident #56 complained of left side forehead pain, no injuries identified. Resident #56 reported to staff that Resident #59 called her a dumbo and hit her with a rounded object (trashcan). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 3 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0600 Level of Harm - Actual harm Residents Affected - Few Review of the SRI number dated 04/21/23 revealed Resident #56 was heard yelling from her room. When staff entered, they found an over bed table flipped over and Resident #56 had a trashcan on her head while she was lying in bed. The report did not include statements, but the responding staff wrote progress notes. Interview on 05/24/23 at 2:05 P.M. with Resident #56 revealed she was not afraid and did not remember being hit. Interview on 05/24/23 at 2:07 P.M. with Registered Nurse #63 revealed she did not witness the incident but went to Resident #56's room due to a scream and found Resident #59 in there and Resident #56 had a trash bin on top of her head while she was laying on her bed. The bedside table had also been knocked over onto the floor. No injuries were noted. RN #63 revealed Resident #59 gets frustrated and he would get mad and slam his wheelchair or walker into staff or walls/doors but denied seeing him get physical with another resident. Interview on 05/24/23 at 3:44 P.M. with the DON and Corporate Nurse #130 revealed Resident #59 was placed on 1:1 supervision until he transferred to the hospital for a urinary tract infection (UTI). 4. Review of the medical record for Resident #75 revealed an admission date of 04/11/22. Diagnoses included Alzheimer's disease, dementia with anxiety, cerebrovascular disease and diabetes. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #75 was cognitively impaired and required supervision assistance for all activities of daily living and limited assistance with transfers. Review of the progress notes dated 05/03/23 revealed Resident #75 reported to staff that Resident #59 was in her bed and when she tried to get him out of her bed, Resident #59 kicked her in the stomach. Review of the SRI dated 05/03/23 revealed Resident #75 reported Resident #59 kicked her in the stomach when attempting to get Resident #59 out of her bed. Staff removed Resident #59 from Resident #75's bed, assessed both residents and contacted all necessary parties. Residents were assessed with no known injuries. The investigation included statements: CNA #27 reported she did not see the event but had last seen Resident #59, 20 to 25 minutes prior, when she put him in his own bed. CNA #95 reported Resident #75 informed her of the altercation CNA observed Resident #59 in Resident #75's bed CNA along with additional staff entered the room and assisted Resident #59 out of Resident #75's room. Interview on 5/24/23 at 11:45 A.M., with CNA #95 revealed Resident #59 was in his bed sleeping right before the incident. CNA #95 revealed Resident #59 got out of bed by himself and walked into Resident#75's room and laid in her bed and when she tried to get him out of it Resident #59 kicked and hit Resident #75. CNA #95 revealed Resident #59 often became physically aggressive when he was aggravated and upset and had seen him become aggressive with residents previously. CNA #95 also revealed Resident #59 would get aggravated by things such as too much noise. Interview on 05/24/23 at 1:58 P.M. with Resident #75 revealed she remembered the incident and could point out the person who hurt her in the incident. Interview on 05/24/23 at 3:44 P.M., with the DON and Corporate Nurse #130 revealed Resident #59 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 4 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0600 Level of Harm - Actual harm Residents Affected - Few not placed on 1:1 supervision after this incident due to staff believed it was due to him being in another resident's bed and that it was more situational as he thought it was his bed. Signs were placed on resident #59's door to help him find it easier. 5. Review of the medical record for Resident #18 revealed an admission date of 04/06/23. Diagnoses included traumatic subarachnoid hemorrhage without loss of consciousness, and dementia with agitation. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #18 was cognitively impaired and required extensive assistance for all activities of daily living. Review of the progress notes dated 05/06/23 as late entry revealed a head-to-toe assessment done and unable to recall the incident from 05/05/23. Review of the SRI dated 05/05/23 revealed Resident #59 had 1:1 supervision and was observed by staff to flip over a table and spill/throw coffee on Resident #18. The investigation included statements: Licensed Practical Nurse (LPN) #131 reported Resident #59 was in the dining room and without any trigger, Resident #59 threw coffee at Resident #18. The coffee was lukewarm and sitting on the table for sometime before the incident occurred. Resident #18 had no injuries related to the incident. Interview on 05/24/23 at 1:55 P.M. with Resident #18 revealed he did not remember anyone hitting him or hurting him. Interview on 05/24/23 at 3:44 P.M. with DON and Corporate Nurse #130 revealed while Resident #59 was on 1:1 supervision, he flipped over a table and threw coffee on Resident #18. Resident remained on 1:1 supervision until he was seen by the neurologist and had medication changes on 05/18/23. Review of facility policy titled OHIO Abuse, Neglect and Misappropriation, undated revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. In the event the alleged abuse involves a resident-to-resident altercation, the residents would be placed in separate areas by the staff and resident safety was the priority. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 5 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #83 was admitted to the facility on [DATE]. Diagnoses included schizophrenia disorder, psychotic disorder, depression, and anxiety. Residents Affected - Some Review of the PASRR determination from the Ohio Department of Mental Health dated [DATE] from the acute care facility did not list schizophrenia as a diagnosis. Review of the admitting diagnoses for [DATE] revealed a current diagnosis of schizophrenia. Review of the medical record revealed no evidence of a corrected PASRR was submitted for approval to the state agency after admission on [DATE]. Interview on [DATE] at 4:00 P.M., with the Director of Social Services #65 verified a correct PASRR was not completed for Resident #83. 2. Review of the electronic record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included delusional disorders, vascular dementia with other behavioral disturbance, delusional disorders, major depressive disorder, and psychosis not due to a substance or known physiological condition. Review of the PASSR screening revealed the most recent one was completed on [DATE]. Review of the clinical record revealed Resident #01 had a diagnosis of Major Depressive Disorder dated [DATE]. This was not listed on the initial PASSR screening and the screening was not redone. An interview was conducted with the Director of Social Services #65 on [DATE] at 11:20 A.M., who verified the PASSR screening had not been redone after the new diagnosis. Based on medical record review, staff interview, and policy review, the facility failed to ensure an accurate preadmission screening resident review (PASRR) was completed on newly admitted residents that had an expired hospital exemption and a history of mental illness. This affected four residents (#01, #59, #77 and #83) out of four residents reviewed for PASRR. The facility census was 91. Findings include: 1. Review of the medical record revealed Resident #77 admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, hallucinations, unspecified mood affective disorder, post-traumatic stress disorder, anxiety disorder and dementia in other diseases classified elsewhere without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #77's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and Resident #77 required extensive assistance with bed mobility, eating, personal hygiene, transfers, dressing, toilet use, and personal hygiene. Review of Resident #77's physician order dated [DATE] revealed Resident #77 admitted to hospice services on [DATE] with a diagnosis of Parkinson's disease. Review of the PASRR dated [DATE] revealed Resident #77 did not have indications of serious mental illness. Resident #77's diagnoses of hallucinations, unspecified mood affective disorder, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 6 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some post-traumatic stress disorder, and anxiety disorder were not listed on the PASRR. Resident #77's PASRR's revealed there was not a significant change PASRR or notification to the state mental health authority upon his admission to hospice services on [DATE]. Interview on [DATE] at 8:34 A.M., with the Director of Social Services #65 verified Resident #77's PASRR dated [DATE] did not include his diagnoses of hallucinations, unspecified mood affective disorder, post-traumatic stress disorder, and anxiety disorder. The Director of Social Services #65 also verified Resident #77 did not have any significant change PASRRs or notifications to the state mental health authority after Resident #77 admitted to hospice services on [DATE]. Review of the facility policy titled PASRR dated [DATE] revealed all individuals must be screened for indications of serious mental illness. 4. Review of the medical record for the Resident #59 revealed an admission date of [DATE]. Diagnoses included Parkinson's disease, bipolar disorder, psychotic disorder with delusions due to known physiological condition, depression, generalized and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance from staff for activities of daily living and supervision with eating. Review of the PASRR dated [DATE] revealed section E: indications for serious mental illness only had other psychotic disorder marked. Interview on [DATE] at 10:02 A.M., with the Director of Social Services #65 revealed Resident #59's PASRR only included other psychotic disorder in the indications for serious mental illness section. Social Services #65 revealed if the diagnosis was not named specifically in the diagnosis list, it would not be included on the PASRR section E. She also confirmed bipolar disorder was not marked as a mood disorder and anxiety was not documented on the PASRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 7 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's fall interventions were in place. This affected one resident (#54) out of five residents reviewed for falls. The facility census was 91. Findings include: Review of the medical records revealed Resident #54 admitted to the facility on [DATE]. Diagnoses included acute embolism and thrombosis of left femoral vein, Alzheimer's disease, dementia with behavioral disturbance, hypertension, and alcohol dependence with alcohol induced persisting dementia. Review of Resident #54's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and Resident #54 required extensive assistance with bed mobility, eating, personal hygiene, transfers, dressing, toilet use, and personal hygiene. Resident #54 also had two or more falls with no injury and two or more falls with injury except major injury on the assessment. Review of Resident #54's fall care plan initiated 05/13/21 revealed Resident #54 was at risk for falls due to the disease process, gait and balance problems, impaired cognition, incontinence, medications, hearing loss and weakness. Interventions included apply dycem to the wheelchair seat to prevent the resident from slipping out of the chair every shift for intervention. Observation on 05/23/23 at 9:38 A.M. revealed Resident #54 propelled himself in his manual wheelchair with non-skid socks on his feet. There was no dycem in Resident #54's wheelchair. Interview on 05/23/23 at 9:38 A.M., with Registered Nurse (RN) #75 verified Resident #54 was propelling himself in his manual wheelchair in the hallway and he had no dycem in his wheelchair to prevent him from slipping out. Review of the policy titled Fall Prevention and Management, dated 06/01/22 revealed a care plan should be initiated that includes a plan to potentially diminish the risk of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 8 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was provided dental services and timely care after the loss of dentures. This affected one resident (#47) out of three residents reviewed for dental. The facility census was 91. Residents Affected - Few Findings include: Review of the medical record revealed Resident #47 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, end stage renal disease, schizoaffective disorder, dysphagia, and weakness. Review of Resident #47's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment and Resident #47 required extensive assistance with bed mobility, personal hygiene, transfers, dressing, toilet use, and personal hygiene. Resident #47 required supervision with eating and Resident #47 had no natural teeth or tooth fragments and was edentulous. Review of Resident #47's dental care plan dated 05/02/22 revealed the resident had the potential for dental problems and was edentulous and wore full dentures. Interventions included dental consults as needed and observe for dental problems. Observation on 05/21/23 at 10:17 A.M. revealed Resident #47 was laying in bed. Resident #47 had no natural teeth and was edentulous without dentures. Interview with Resident #47's resident representative on 05/21/23 at 5:24 P.M., revealed Resident #47 was missing her dentures at the facility and the facility had not replaced them. Interview on 05/23/23 at 10:40 A.M., revealed with the Director of Social Services #65 was not aware of Resident #47 missing dentures or having dentures. The Director of Social Services #65 verified Resident #47 had not been seen by the dentist since she was admitted to the facility on [DATE]. Interview on 05/23/23 at 9:11 A.M., with the Licensed Practical Nurse Unit Manager (LPN) #36 verified Resident #47 did not have any natural teeth or was edentulous. LPN Unit Manager #36 verified she was not aware of Resident #47 having dentures and had never seen Resident #47 wear dentures at the facility. LPN Unit Manager #36 also confirmed Resident #47's care plan stated Resident #47 wore dentures but she did not know what happened to Resident #47's dentures. Review of the facility policy titled Denture Loss or Damage, undated revealed dentures that are reported broken or lost shall be replaced with assistance of facility staff. A referral will be made within three days of missing or broken dentures being reported. Dentures that have been reported missing or broken to nursing staff will be directed to social services. The facility will replace lost dentures at the cost of the facility if the investigation reveals the facility was negligent or irresponsible with handling and the resident had dentures on admission. Review of the facility policy titled Dental Services, revealed the facility will assist the resident with obtaining routine dental services. The facility will promptly within three days refer residents with lose or damaged dentures for dental services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 9 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff and resident interview, review of the food temperature logs, and policy review, the facility failed to ensure hot foods were maintained at a safe and palatable holding temperature. This affected 45 Residents (#01, #02, #09, #15, #16, #17, #20, #24, #25, #26, #30, #33, #36, #38, #40, #43, #44, #45, #46, #51, #52, #54, #55, #60, #61, #62, #63, #64, #66, #68, #71, #72, #73, #74, #75, #76, #78, #79, #83, #84, #85, #88, #89, #193, #292) of 45 residents who had a diet order for regular texture foods. The facility census was 91. Residents Affected - Some Finding include Interview on 05/21/23 at 3:35 P.M. with Resident #02 revealed the food tasted bad because hot foods do not come out hot. Observation on 05/23/23 at 12:10 P.M. revealed Dietary Staff #48 took food temperatures of cooked potatoes cubes that resulted at 132 degrees Fahrenheit. Dietary Staff #48 wrote the temperature of 132 degrees Fahrenheit on the food temperature log. Observation of the test tray revealed the tray revealed the plate was put on a warmer and was placed on a non insulated cart and taken to the unit at 12:40 P.M. The tray passing commenced at 12:53 P.M. and temperatures were take of the test tray. The potatoes on the test tray were temped at 113-114 degrees Fahrenheit and tasted luke warm. The Dietary Manager #15 declined to try the test tray. Review of Food Temperature log: - dated 05/12/23 revealed spaghetti had a temperature documented of 129 degrees Fahrenheit - dated 05/19/23 revealed burgers had a temperature documented of 132 degrees Fahrenheit - dated 05/20/23 revealed zucchini had a temperature documented of 122 degrees Fahrenheit and the quesidilla had a temperature documented of 121 degrees Fahrenheit - dated 05/21/23 revealed fries had a temperature documented of 122 degrees Fahrenheit and the salad had a documented temperature of 64 degrees Fahrenheit. - The facility was unable to provide food temperature logs for 05/23/23 and 05/24/23 Review of the facility policy titled Dining Procedures Policy and Procedure Manual, dated 09/2017 revealed all foods would be held and monitored at appropriate temperatures greater than 135 degrees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 10 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to ensure safe and sanitary storage practices were in place, failed to store kitchen and service equipment in a safe and sanitary manner, failed to ensure the high temperature dishwasher was getting to proper temperature, and failed to ensure food preparation and cooking services were maintained in clean and sanitary manner. This had the potential to affect all 91 residents who eat from from the kitchen. The facility census was 91. Findings include 1. Observation and interview on 05/21/23 at 9:33 A.M. with Dietician #125 revealed and confirmed the following food storage concerns: - a remade salad in the refrigerator was undated - a pitcher of orange juice was undated - an opened pack of cheese was undated - a large bag of salt was found open to air and undated - a large container of thickener powder was open to air and was undated - a plastic bin of flour was found with the door open and left open to air and was also undated - a bag of dried pasta was found open to air due to a large hole ripped in the bag. - a bag of frozen beans were left undated in the freezer Interview on 05/23/23 at 12:25 P.M. with Dietary Manager (DM) #15 confirmed history of food storage issues and revealed staff needed training. Review of facility policy titled Food Storage: Dry Goods, dated 09/2017 revealed all dry goods would be appropriately stored. Food items shall be kept properly sealed and all items should have a date marked for easy identification. Review of facility policy titled Food Storage: Cold Goods, dated 04/2018 revealed all dry goods would be appropriately stored. Food items shall be kept properly covered, labeled and dated. 2. Observation on 05/23/23 from 11:04 A.M. to 12:25 P.M. revealed a prep table where the pureed food was being made had a storage rack underneath it that contained two large metal cooking pans that were stored upside down and three cutting boards stored in a vertical rack. The shelf was covered in grime, grease and crumbs that were both loose on the shelf and also crumbs that were caked on the shelf. The shelf also had sections with rust and several items of trash on it including a plastic disposable lid, a wrapper and a dirty glove. The steam table had a shelf beneath it which contained one metal cooking pan that was stored upright and had splattered and a puddle of dried grease it in a and a separate stack of five bowls sitting upright. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 11 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 05/23/23 at 12:25 P.M. with DM #15 confirmed the shelves under the prep table and the warming table were dirty with kitchen equipment and trash items on them. The DM #15 confirmed equipment storage space should be maintained cleaned and sanitary. 3. Observation on 05/23/23 at 11:04 A.M. revealed Dietary Staff #48 was making pureed foods. On the prep table was a dirty cutting board that was covered in loose crumbs. The spoons and spatulas used to pureed food were placed on the dirty cutting board. When Dietary Staff #48 would use a spoon or spatula the wet or dirty spoon would be placed on the loose crumbs and when used again the spoon had crumbs on it that would be placed in the roboku blender to stir up the food mixtures or to put in a metal dish for service. Interview on 05/23/23 at 12:25 P.M. with DM #15 confirmed the food preparation area should be maintained in a clean and sanitary manner. DM confirmed food prep area was covered in crumbs. 4. Observation on 05/23/23 at 12:06 P.M. revealed the flat top griddle was covered in food (eggs) from the breakfast meal. Dried food residue was on the flat top and was also along the edges and base. Dietary Staff #39 was observed to make fresh grilled cheese sandwiches on the dirty griddle without cleaning it. Dietary Staff #39 confirmed the grill had not been cleaned prior to using it again. It was observed when the grilled cheese were flipped on the flat top grill, pieces of eggs were cooked into the bread. Interview on 05/23/23 at 12:25 P.M., with the DM #15 confirmed staff cooked the grill cheese sandwiches on a dirty flat top that had not been cleaned from the breakfast meal and still contained food (egg) particles. The DM #15 revealed the cooking area should be maintained clean and sanitary. 5. Observation and interview on 05/23/23 at 12:15 P.M. revealed dietary staff #48 took food temperatures. The thermometer was put in the pureed chicken then without sanitizing, the thermometer was placed in the broccoli, again without sanitizing, the thermometer was placed in meatballs. Dietary Staff #48 confirmed the thermometer was not sanitized in between each food item. Review of facility policy titled Food Preparation, dated 09/2017 revealed all utensils, food contact equipment and food contact surfaces would be cleaned and sanitized after every use. Review of facility policy titled Equipment, dated 09/2017 revealed all food service equipment will be clean, sanitary, and in proper working order. All food contact equipment would be cleaned and sanitized after every use and non food contact equipment would be kept clean and free of debris FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 12 of 13 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 365722 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Glen Alzheimer's Community 3800 Summit Glen Drive Dayton, OH 45449 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure medications were prepared using proper infection control technique. This affected one resident (#13) out of three residents (#13, #61, and #70) observed for medication administration. The facility census was 91. Residents Affected - Few Findings included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, systemic inflammatory response syndrome, acute cystitis, acute kidney failure, cardiomyopathy, type II diabetes, Parkinson's disease, schizophrenia, Alzheimer's disease, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had severe cognitive impairment. He needed extensive assist of one staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. Observation was made on 05/23/23 at approximately 8:18 A.M. of Registered Nurse (RN) #74 preparing medication for Resident #13. RN #74 was observed pouring the resident's medication in her ungloved hand as she was placing the medications into a plastic sleeve to crush. An interview with RN #74 on 05/24/23 at approximately 8:30 A.M., indicated she felt it was alright for her to pour the medications in her bare hand because she washed her hands. An interview with the Registered Nurse Divisional Director of Clinical Operations #150 on 05/24/23 at 3:07 P.M. She said the nurse should not have handled the medication with her bare hands. Review of the policy titled Medication Administration, revised 12/14/17 revealed full attention should be given during preparation of medications, avoiding distractions is important for infection prevention and reducing errors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365722 If continuation sheet Page 13 of 13