Inspection·February 12, 2020

F 0580 • Level of Harm - Minimal harm or potential for actual harm On 12/02/19, he weighed 148 lbs. • Residents Affected - Few On 01/02/20, he weighed 142 lbs. • On 01/20/20, he weighed 143 lbs. • On 02/02/20, he weighed 140 lbs. • On 02/11/20, he weighed 142 lbs. with his boots on and 139 lbs. without his boots. Review of the resident's medical record revealed there was no explanation why the weights on 09/13/19, 10/03/19 and 10/05/19 were striked out by Dietitian #160. There was no evidence the physician was notified of the resident's weight loss from 11/02/19 through 02/02/19 despite the resident showing significant weight loss on 11/02/19, 12/01/19, 01/02/20 and 01/20/20. Interview with the Director of Nursing (DON) on 02/11/20 at 11:00 A.M. revealed the weights were wrong and the dietician who striked them out was off on leave and could not be reached. The DON verified there wasn't any documentation as to why the weights were striked out. Interview with the Nurse Practitioner (NP) #161 on 02/11/20 at 5:03 P.M. revealed she was only notified on 02/04/20 of the weight loss for Resident #35. She stated her expectation would be to report weight loss of 5% to 10% in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 2 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Based on medical record review, staff interviews, review of the facility's Self-Reported Incident and review of the facility's abuse policy, the facility failed to implement their abuse policy by not thoroughly investigating an allegation of abuse and reporting an allegation of abuse to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Residents Affected - Few Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar names, including racial slurs. When LPN #141 attempted to intervene, the resident then called this nurse a 'expletive'. Resident #4 was trying to stand up, out of his wheelchair with his fists clinched. Resident was then redirected to remove himself from the shower room to avoid further conflict. On 12/24/19 at 7:06 A.M., Resident #35 came to the nurse (LPN #141) at 6:50 A.M. crying and stating that he was scared to go back into his room for fear that Resident #6 was going to hurt him. Resident #35 stated Resident #4 was becoming verbally abusive and physically threatening him. The resident stated that he does not want to be in this facility anymore due to he was scared to be here. He stated that he was going to contact his family to be removed from facility and move to another facility and he does not feel safe. The nurse moved Resident #35 to another room, temporarily until other means can be met. It was reported to the Administrator. Review of the facility's soft folder investigation, dated 12/24/19 signed by the Administrator, revealed Resident #35 had a conflict with Resident #4. The resident stated he had an issue with his roommate hollering at him, didn't know what he said but said it was loud, he wanted a new roommate and felt safe in the facility. Review of the facility's Self-Reported Incidents (SRIs) from 12/23/19 through 02/12/20 revealed there wasn't any filed for this allegation involving Resident #35. Interview with the Administrator on 02/10/20 at 1:56 P.M. verified he didn't complete an investigation involving Resident #35 and verified he didn't report the allegation of abuse involving Resident #35 to the State Survey Agency. He stated he felt like Resident #35 was moved to a different room and it solved the issue. The Administrator said he didn't recall the nurse reporting Resident #35 felt like Resident was verbally abusive and physically threatening him and he was scared to go back into his room. At 3:13 P.M., the Administrator brought in a soft file with one piece of paper, with an investigation he had done. He stated the nurse told him there were two residents not getting along and Resident #35 came up to the desk and was tearful and not getting along with his roommate. The Administrator verified he did not obtain statements from the resident, witnesses and interview any other residents that may have witnessed the event or felt abused by Resident #4. Interview with LPN #141 on 02/11/20 at 12:01 P.M. revealed Resident #4 had behaviors and cursed at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 3 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Residents Affected - Few times. She said she heard some yelling in the room but couldn't make out what was being said between Resident #35 and #4. She stated Resident #35 came out to the nursing station and was tearful, upset and said he didn't want to be in the facility anymore. She said she thought Resident #35 was scared and wasn't used to being cursed at. She denied Resident #4 had acted on his cursing. She stated she changed rooms so Resident #35 would feel safe and comfortable. She stated she called the Administrator to informed him of the room change. She stated she could have been over zealous in the way she wrote the note, because she felt like Resident #35 was feeling verbally abused and physically threatened. She denied she filled out a statement of events for an investigation. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation and Crime Reporting, dated 10/01/19, revealed every resident had the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion. Investigation of suspected or alleged abuse will be investigated and documented timely. Individuals with knowledge of, or potential knowledge of, the allegation situation will be interviewed, and handled confidentially. It is a requirement that reporting happen within two hours or as soon as practically possible, of notification of suspected abuse neglect, or misappropriation or resident property to the state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 4 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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. Based on medical record review, staff interview, review of the facility's Self-Reported Incident and policy review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar names, including racial slurs. When LPN #141 attempted to intervene, the resident then called this nurse a 'expletive'. Resident #4 was trying to stand up, out of his wheelchair with his fists clinched. Resident was then redirected to remove himself from the shower room to avoid further conflict. On 12/24/19 at 7:06 A.M., Resident #35 came to the nurse (LPN #141) at 6:50 A.M. crying and stating that he was scared to go back into his room for fear that Resident #6 was going to hurt him. Resident #35 stated Resident #4 was becoming verbally abusive and physically threatening him. The resident stated that he does not want to be in this facility anymore due to he was scared to be here. He stated that he was going to contact his family to be removed from facility and move to another facility and he does not feel safe. The nurse moved Resident #35 to another room, temporarily until other means can be met. It was reported to the Administrator. Review of the facility's Self-Reported Incidents (SRIs) from 12/23/19 through 02/12/20 revealed there wasn't any filed for this allegation involving Resident #35. Interview with the Administrator on 02/10/20 at 1:56 P.M. verified he didn't report the allegation of abuse involving Resident #35 to the State Survey Agency. He stated he felt like Resident #35 was moved to a different room and it solved the issue. The Administrator said he didn't recall the nurse reporting Resident #35 felt like Resident was verbally abusive and physically threatening him and he was scared to go back into his room. At 3:13 P.M., the Administrator brought in a soft file with one piece of paper, with an investigation he had done. He stated the nurse told him there were two residents not getting along and Resident #35 came up to the desk and was tearful and not getting along with his roommate. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation and Crime Reporting, dated 10/01/19, revealed every resident had the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion. It is a requirement that reporting happen within two hours or as soon as practically possible, of notification of suspected abuse neglect, or misappropriation or resident property to the state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 5 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Based on medical record review, staff interview, and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Residents Affected - Few Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar names, including racial slurs. When LPN #141 attempted to intervene, the resident then called this nurse a 'expletive'. Resident #4 was trying to stand up, out of his wheelchair with his fists clinched. Resident was then redirected to remove himself from the shower room to avoid further conflict. On 12/24/19 at 7:06 A.M., Resident #35 came to the nurse (LPN #141) at 6:50 A.M. crying and stating that he was scared to go back into his room for fear that Resident #6 was going to hurt him. Resident #35 stated Resident #4 was becoming verbally abusive and physically threatening him. The resident stated that he does not want to be in this facility anymore due to he was scared to be here. He stated that he was going to contact his family to be removed from facility and move to another facility and he does not feel safe. The nurse moved Resident #35 to another room, temporarily until other means can be met. It was reported to the Administrator. Review of the facility's soft folder investigation, dated 12/24/19 signed by the Administrator, revealed Resident #35 had a conflict with Resident #4. The resident stated he had an issue with his roommate hollering at him, didn't know what he said but said it was loud, he wanted a new roommate and felt safe in the facility. Interview with the Administrator on 02/10/20 at 1:56 P.M. verified he didn't complete an investigation involving Resident #35. He stated he felt like Resident #35 was moved to a different room and it solved the issue. The Administrator said he didn't recall the nurse reporting Resident #35 felt like Resident was verbally abusive and physically threatening him and he was scared to go back into his room. At 3:13 P.M., the Administrator brought in a soft file with one piece of paper, with an investigation he had done. He stated the nurse told him there were two residents not getting along and Resident #35 came up to the desk and was tearful and not getting along with his roommate. The Administrator verified he did not obtain statements from the resident, witnesses and interview any other residents that may have witnessed the event or felt abused by Resident #4. Interview with LPN #141 on 02/11/20 at 12:01 P.M. revealed Resident #4 had behaviors and cursed at times. She said she heard some yelling in the room but couldn't make out what was being said between Resident #35 and #4. She stated Resident #35 came out to the nursing station and was tearful, upset and said he didn't want to be in the facility anymore. She said she thought Resident #35 was scared and wasn't used to being cursed at. She denied Resident #4 had acted on his cursing. She stated she changed rooms so Resident #35 would feel safe and comfortable. She stated she called the Administrator to informed him of the room change. She stated she could have been over zealous in the way she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 6 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete wrote the note, because she felt like Resident #35 was feeling verbally abused and physically threatened. She denied she filled out a statement of events for an investigation. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation and Crime Reporting, dated 10/01/19, revealed every resident had the right to be free from verbal, sexual, physical, and mental abuse; neglect, corporal punishment, and involuntary seclusion. Investigation of suspected or alleged abuse will be investigated and documented timely. Individuals with knowledge of, or potential knowledge of, the allegation situation will be interviewed, and handled confidentially. Event ID: Facility ID: 365743 If continuation sheet Page 7 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 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. Based on observation, staff interview and record review, the facility failed to develop a person-centered plan of care for a resident who received oxygen. This affected one (Resident #32) of eighteen residents reviewed during the annual survey. The facility census was 75. Findings included: Review of Resident #32's medical record revealed an admission date of 03/13/16 with diagnoses including pneumothorax, generalized anxiety disorder, malignant neoplasm of the lungs, chronic obstructive pulmonary disease and dementia. Review of the physician order, dated 09/10/19, revealed orders to rinse and replace intake filter every week and to change oxygen tubing every twenty-eight days. On 11/29/19, an order to monitor oxygen saturation every shift. On 12/16/19, there were orders to have the humidification to the oxygen to be continuous and administer oxygen at two liters per minute per nasal cannula continuous. Review of the Minimum Data Set (MDS) assessment, dated 12/31/19, revealed the resident was ordered and received oxygen. Review of Resident #32's plan of care dated 12/31/19 revealed no reference or interventions related to oxygen. Observation on 02/09/20 at 10:32 A.M. with Resident #32 revealed the resident was pacing in the room with a long oxygen tubing reaching out into the hallway. Interview on 02/12/20 at 10:37 A.M. with Licensed Practical Nurse (LPN) #137 revealed she was not aware of Resident #32 having had any falls related to the oxygen tubing. LPN #137 stated the staff do have to remind him frequently about the tubing. LPN #137 stated shorter tubing was attempted, however the resident became very anxious and the longer tubing was put back in place. Interview on 02/12/20 at 11:04 A.M. with the Director of Nursing confirmed the resident did not have interventions related to oxygen included in Resident #32's plan of care. The DON stated her expectation was the oxygen should be included on the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 8 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Based on record review, observation, review of the facility's policy and staff interview, the facility failed to hold activities that met the needs of the residents residing on the memory care unit. This affected three (Resident #10, #11, and #63) of three residents reviewed for activities. This had the potential to affect all 11 residents residing on the memory care unit. The facility census was 75. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 08/10/16 with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and anxiety. Review of the quarterly Minimum Data S(MDS) assessment, dated 11/06/19, revealed the resident was rarely/never understood and required limited to extensive staff assist with all activities of daily living (ADL) aside from eating and walking in her room. Review of the activity care plan revealed the resident response to music activities, exercise, enjoys walking with staff, and interacting with other residents and needs one on one assistance in groups. The goal was for the resident to take part in daily activities on the unit daily. Interventions included to walk with Resident #10 to daily activities, provide direction as needed, take for walks outside on nice days and provide opportunity to interact with others. Observation of Resident #10 on 02/11/20 at 8:40 A.M., 8:58 A.M., 9:54 A.M., 2:07 P.M., and 2:34 P.M., revealed Resident #10 was seated in the common area of the memory care unit. Resident #10 was not actively engaged in any activities during any of these observations. There were no structured activities being held during these times observed in the memory care unit. Subsequent observation on 02/12/20 at 9:41 A.M. revealed the resident was seated on the couch in the common area while other residents engaged in an activity. Resident #10 was not actively engaged in the activity and no staff were observed encouraged her to engage in the activity. 2. Review of the medical record for Resident #11 revealed an admission date of 02/28/19 with diagnoses including Alzheimer's disease, cerebral infarction, anxiety, and vascular dementia without behavioral disturbance. Review of the quarterly MDS assessment, dated 11/13/19, revealed the resident was cognitively intact. Review of the activity care plan revealed Resident #11 enjoyed groups, including music programs, religious events, and individual and self-directed activities of family visits and relaxing in room. The goal was Resident #11 will engage in activities that match his skills, abilities, and/or interests every week for three months. Interventions included to provide any needed supplies and assistance for activities as well as give direction as needed and provide verbal reminders of activities of choice, assist as needed to attend, and invite to lunch outings and walk with resident to Friday afternoon music group and bluegrass band on Wednesday evening. Observation of Resident #11 on 02/11/20 at 8:43 A.M., 9:54 A.M., and 2:34 P.M. revealed he was seated in his room and not actively engaged in any activities. Subsequent observation of Resident #11 on 02/12/20 at 9:40 A.M. revealed he was seated in his room while other residents participated in an activity in the common area. Resident #11 was not observed actively engaged in any activities and no staff were observed encouraging him to engage in the activity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 9 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the medical record for Resident #63 revealed an admission date of 08/09/19 with diagnoses including Alzheimer's disease, bipolar disorder, and depression. Review of the quarterly MDS assessment, dated 12/31/19, revealed the resident was severely cognitively impaired. Review of the activity care plan revealed the resident impaired activity and recreation pursuits related to social, physical, and cognitive loss/dementia. The care plan goal was Resident #63 will engage in activities that match her skills, abilities, and interests every week for three months. The care plan intervention included to provide one to one in-room visits if Resident #63 was unable or chooses not to attend activities. Review of the facility's activity calendar, dated 02/10/20 through 02/12/20, revealed the coffee cart was scheduled as an activity at 9:00 A.M. on each of these days, music and movement was scheduled for 9:30 A.M. on each of these days, morning devotional was scheduled at 10:00 P.M. on each of these days, table games was scheduled at 11:00 A.M. on 02/10/20, bingo was scheduled at 2:00 P.M. on 02/10/20, room visits were scheduled at 3:30 P.M. on 02/10/20, women's group was scheduled at 11:00 A.M. on 02/11/20, bingo was scheduled at 2:30 P.M. on 02/11/20, upland community worship was scheduled at 6:30 P.M. on 02/11/20, grace Baptist church was scheduled at 10:30 A.M. on 02/12/20, pretty nails was scheduled at 11:00 A.M. on 02/12/20, movie and popcorn was scheduled at 3:30 P.M. on 02/12/20, and blue grass band was scheduled at 6:30 P.M. on 02/12/20. There was no mention of any specific activity to occur in the memory care unit. Observation of Resident #63 on 02/10/20 at 1:37 P.M. revealed Resident #63 was in her room laying in bed. Subsequent observation of Resident #63 on 02/11/20 at 8:43 A.M., 8:59 A.M., 9:01 A.M., 9:55 A.M., and 2:35 P.M., revealed Resident #63 was in her room and not actively engaged in activities on each of these observations. Observation of the memory care unit on 02/10/20 from 8:58 A.M. through 9:54 AM revealed no structured activities were held during this time period. Subsequent observations on 02/10/20 at 11:16 A.M., on 02/10/20 from 3:25 P.M. through 3:54 P.M.,on 02/11/20 at 9:20 A.M. and 10:12 A.M. and on 02/12/20 at 8:39 A.M. no structured activities were held during this timeframe. Interview with Activity Manager (AM) #125 on 02/12/20 at 8:25 A.M. revealed there was an activity aide who was responsible for completing activities on the memory care unit. The interview further revealed AM #125 started at the facility roughly six weeks ago and has been trying to build a more individualized activity program. During the interview, AM #125 stated that if the activity aide was not working then the nurse aides and nurses were responsible for completing activities on the memory care unit. Subsequent interview with AM #125 on 02/12/20 at 9:33 A.M. revealed she considers meals to be an activity on the memory care unit. On 02/12/20 at 10:36 A.M., the AM stated the activities on the memory care unit could improve. Interview with Activity Aide (AA) #126 on 02/12/20 at 10:29 A.M. revealed she has been an activity aide since August 2019. The interview further revealed AA #126 holds group activities on the memory care unit roughly two to three times a day however she does not document whether or not residents attend the activities on the memory care unit. AA #126 stated she talks to Resident #63, offers snacks, and plays music such as bluegrass music but had not played any music for Resident #63 from 02/09/20 through 02/12/20. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 10 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy titled Activity Calendar/Schedule revealed in addition to having the activities included to a written calendar or schedule, use a variety of methods, according to residents' preferences and communication needs, to announce daily programs such as: verbal offers to residents on an individual basis, posting of announcements on in-room activity calendars, and upcoming activity invitations, flyers, or table-top announcements. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 11 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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, medical record review, interview with staff and resident and policy review, the facility failed to ensure adequate supervision of a resident who had a history of smoking in the facility. This affected one (#6) of two residents reviewed for smoking. The facility identified eight residents who were independent smokers. Findings include: Medical record review for Resident #6 revealed an admission dated of 07/19/19. Medical diagnoses included coronary artery disease, heart failure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/04/20, revealed the resident was cognitively intact. Review of the care plan, dated 7/19/19, revealed the resident was at risk for smoking related to disease and illness and/or injury. The smoking assessment was completed and the resident was deemed a safe and independent smoker. Interventions were to observe and report unsafe smoking practices. Review of the smoking assessments, dated 07/19/19 and 09/05/19, revealed he was assessed as an independent smoker. Review of the progress note, dated 01/7/20 at 10:28 P.M. revealed the resident was observed smoking in his room. The nurse told the resident to Put it out now, you can not smoke in the building. You may take yourself outside to the smoking area to smoke but not in the room. This nurse took his pack of cigarettes and lighter that was on the table. The resident put out the cigarette but refused to give it to the nurse and the resident stated it's out. Interview and observation of Resident #6 on 02/09/20 at 3:08 P.M. revealed he was getting ready to go outside and smoke and stated he had a cigarette lighter in his pocket and pulled it out of his jacket pocket and said he doesn't turn it in after smoking because it takes too long to get it back and he had lost eight lighters due to turning them in at the nursing station. Interview with State Tested Nursing Aide (STNA) #188 on 02/10/20 at 4:39 P.M. verified he had a lighter in his pocket on this day and time. The STNA stated as far as he was concerned if the smoker was independent they could keep their lighters on themselves and that was the policy of the facility as well. He stated there had been problems with Resident #6 because he had been caught smoking in his room and the staff were supposed to ensure his lighter was returned to the nursing station after smoking. Interview with the Administrator on 02/12/20 at 1:05 P.M. revealed they talked to Resident #6 and he immediately stopped smoking in his room and never did it before that day and didn't do it after that day. He stated Resident #6 stated he wasn't going to smoke in his room anymore and wouldn't keep smoking materials in his room. He stated he has been turning in his smoking materials to the nursing station. He denied they did an assessment for the resident because he said he wasn't [NAME] to do it anymore and that was that. They feel he was safe and they kept him independent with smoking. Review of the facility's undated policy titled Best Practice Guideline Smoking revealed for the facilities who allow smoking, it is the policy to monitor and evaluate residents for safety related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 12 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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 smoking. Individual facilities have specific smoking rules that are provided to residents and families at the time of admission. Staff will control the distribution of smoking materials (cigarettes, cigars, tobacco, and lighters). Residents are not permitted to keep smoking materials in their rooms at any time. A secured unit will be provided for storage of all smoking materials including cigarettes, cigars, tobacco, and lighters and matches. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 13 of 14 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 365743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wright Rehabilitation and Healthcare Center 829 Yellow Springs - Fairfield Rd Fairborn, OH 45324 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. Based on observation, review of the facility's policy and staff interview, the facility failed to ensure a medication cart was locked. This had the potential to affect twenty-three of twenty-five residents who were independently mobile residing on the west hallway. The facility census was 75. Findings included: Observation on 02/09/20 at 9:11 A.M. of an unlocked and unattended medication cart on the west hall. There were two residents observed independently ambulating in their wheelchairs in the hallway at that time. Licensed Practical Nurse (LPN) #137 was observed sitting at the nursing station at the end of the hall. The medication cart was approximately half-way down the hallway. Interview on 02/09/20 at 9:12 A.M. with the Director of Nursing (DON) confirmed the west hall medication cart was unlocked and unattended. Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/01/07, revealed the facility should ensure all medications are securely stored in a locked cart or locked medication room that is inaccessible by residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365743 If continuation sheet Page 14 of 14