Health inspection·April 20, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm documented in the computer. STNA #125 reported once an aide receives their assignment, they are expected to look up their shower assignments for the shift. STNA #125 verified Resident #53 shower days were scheduled on Mondays and Thursdays evenings and confirmed Resident #53 was not receiving showers as preferred. STNA #125 denied Resident #53 informing her of his choice to change shower days and time. Residents Affected - Few Interview on 04/18/22 at 3:00 P.M., revealed DON reported she asks residents upon admission their preferences for shower days. DON stated Resident #53 informed her today he would like his shower days changed to day time on Tuesdays and Fridays. This deficiency substantiates Complaint Number OH00131213. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 2 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 interviews, review of facility self-reported incidents and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (#5) of three residents reviewed for abuse. The census was 60. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the area. The nurse charted she informed the Director of Nursing (DON). No notes were added by the DON. Review of Resident #5 medical record revealed an admission date of 11/14/14. Diagnoses included Alzheimer, dementia and heart disease. The most recent MDS for Resident #5 dated 01/12/22 revealed the resident was severely cognitively impaired and required extensive assistance of one. The resident requires a wheelchair for mobility. Resident #5 could not be interviewed due to low cognitive abilities. Review of the facility SRI's for 03/11/22 through 03/21/22 revealed no incidents involving Resident #1 or Resident #5. Observation on 04/11/22 at 9:30 A.M. revealed the residents reside on a locked dementia unit. The dementia unit includes both male and females. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed, so she did not report it and could not provide an investigation regarding the incident. The DON noted both resident's were clothed so she did not take the investigation further. Interview with Licensed Practical Nurse (LPN #300) on 04/13/22 at 3:00 P.M. revealed the incident she observed on 03/12/22 between Resident #1 and Resident #5 Resident #1 had his had up Resident #5 pant leg to her thigh. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the Nurse told her Resident #1 put his hand on Resident #5 thigh and she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 3 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 clothed Level of Harm - Minimal harm or potential for actual harm Interview with the Social Worker (SW) #12 on 04/14/22 at 2:00 P.M. revealed she was not told of the allegation at the time of the incident involving Resident #1 and #5. SW #12 was unable to provide and investigation and noted their were no written statements obtained from the staff. Residents Affected - Few Review of the Abuse Policy revised 04/2020 revealed all allegations of abuse are to be reported to the state agency. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the area. The nurse charted she informed the Director of Nursing (DON). No notes were added by the DON. Review of Resident #5 medical record revealed an admission date of 11/14/14. Diagnoses included Alzheimer, dementia and heart disease. The most recent MDS for Resident #5 dated 01/12/22 revealed the resident was severely cognitively impaired and required extensive assistance of one. The resident requires a wheelchair for mobility. Resident #5 could not be interviewed due to low cognitive abilities. Review of the facility SRI's for 03/11/22 through 03/21/22 revealed no incidents involving Resident #1 or Resident #5. Observation on 04/11/22 at 9:30 A.M. revealed the residents reside on a locked dementia unit. The dementia unit includes both male and females. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed, so she did not report it and could not provide an investigation regarding the incident. The DON noted both resident's were clothed so she did not take the investigation further. Interview with Licensed Practical Nurse (LPN #300) on 04/13/22 at 3:00 P.M. revealed the incident she observed on 03/12/22 between Resident #1 and Resident #5 Resident #1 had his had up Resident #5 pant leg to her thigh. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 4 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the Nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed Interview with the Social Worker (SW) #12 on 04/14/22 at 2:00 P.M. revealed she was not told of the allegation at the time of the incident involving Resident #1 and #5. SW #12 was unable to provide and investigation and noted their were no written statements obtained from the staff. Review of the Abuse Policy revised 04/2020 revealed all allegations of abuse are to be investigated and reported to the state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 5 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 interviews, review of facility self-reported incidents and policy review, the facility failed to investigate an allegation of sexual abuse. This affected one (#5) of three residents reviewed for abuse. The census was 60. Residents Affected - Few Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the area. The nurse charted she informed the Director of Nursing (DON). No notes were added by the DON. Review of Resident #5 medical record revealed an admission date of 11/14/14. Diagnoses included Alzheimer, dementia and heart disease. The most recent MDS for Resident #5 dated 01/12/22 revealed the resident was severely cognitively impaired and required extensive assistance of one. The resident requires a wheelchair for mobility. Resident #5 could not be interviewed due to low cognitive abilities. Review of the facility SRI's for 03/11/22 through 03/21/22 revealed no incidents involving Resident #1 or Resident #5. Observation on 04/11/22 at 9:30 A.M. revealed the residents reside on a locked dementia unit. The dementia unit includes both male and females. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed, so she did not report it and could not provide an investigation regarding the incident. The DON noted both resident's were clothed so she did not take the investigation further. Interview with Licensed Practical Nurse (LPN #300) on 04/13/22 at 3:00 P.M. revealed the incident she observed on 03/12/22 between Resident #1 and Resident #5 Resident #1 had his had up Resident #5 pant leg to her thigh. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the Nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 6 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 Interview with the Social Worker (SW) #12 on 04/14/22 at 2:00 P.M. revealed she was not told of the allegation at the time of the incident involving Resident #1 and #5. SW #12 was unable to provide and investigation and noted their were no written statements obtained from the staff. Review of the Abuse Policy revised 04/2020 revealed all allegations of abuse are to be reported to the state agency. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the area. The nurse charted she informed the Director of Nursing (DON). No notes were added by the DON. Review of Resident #5 medical record revealed an admission date of 11/14/14. Diagnoses included Alzheimer, dementia and heart disease. The most recent MDS for Resident #5 dated 01/12/22 revealed the resident was severely cognitively impaired and required extensive assistance of one. The resident requires a wheelchair for mobility. Resident #5 could not be interviewed due to low cognitive abilities. Review of the facility SRI's for 03/11/22 through 03/21/22 revealed no incidents involving Resident #1 or Resident #5. Observation on 04/11/22 at 9:30 A.M. revealed the residents reside on a locked dementia unit. The dementia unit includes both male and females. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the nurse told her Resident #1 put his hand on Resident #5 thigh and she was clothed, so she did not report it and could not provide an investigation regarding the incident. The DON noted both resident's were clothed so she did not take the investigation further. Interview with Licensed Practical Nurse (LPN #300) on 04/13/22 at 3:00 P.M. revealed the incident she observed on 03/12/22 between Resident #1 and Resident #5 Resident #1 had his had up Resident #5 pant leg to her thigh. Interview with the DON on 04/13/22 1:00 P.M. revealed the incident was not reported to the state agency. The DON stated the Nurse told her Resident #1 put his hand on Resident #5 thigh and she was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 7 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 clothed Level of Harm - Minimal harm or potential for actual harm Interview with the Social Worker (SW) #12 on 04/14/22 at 2:00 P.M. revealed she was not told of the allegation at the time of the incident involving Resident #1 and #5. SW #12 was unable to provide and investigation and noted their were no written statements obtained from the staff. Residents Affected - Few Review of the Abuse Policy revised 04/2020 revealed all allegations of abuse are to be investigated and reported to the state agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 8 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #43's medical record revealed the resident was admitted on [DATE] with a readmission on [DATE] from a hospital stay from 01/18/22 through 01/20/22. Diagnoses include epilepsy and seizures. Further medical record review for Resident #43 revealed there was no documented evidence the Ombudsman was notified of the hospital transfer. Interview on 04/13/22 at 11:38 A.M. with the Social Service Director (SSD) #22 revealed she has not notified the Ombudsman of discharges from the facility because the facility was given a new Ombudsman and she was waiting for them to give her their email address. SSD #22 confirmed there was no evidence of the Ombudsman being notified of Resident #14, #28, #43 or #61's transfers to the hospital. Interview on 04/13/22 at 1:28 P.M. with the Director of Nursing (DON) confirmed the facility has not been providing discharge notifications to the Ombudsman. The DON stated the facility is working on putting a program in place to notify the Ombudsman of discharges. 2. Review of medical record for Resident #14 revealed admission date of 12/26/19 no memory impairment cognition modified independence. Diagnoses include congestive heart failure, type 2 diabetes, hypertension, reflux and contracture to left knee. The resident remained at the facility. Review of Resident #14's quarterly MDS dated [DATE] revealed the resident required extensive two assist for bed mobility, transfers, and independent for eating. Record review of the electronic medical record revealed Resident #14 was hospitalized on [DATE] and 09/21/21. Further medical record review for Resident #14 revealed there was no documented evidence the Ombudsman was notified of the hospital transfers. Based on medical record review and staff interview, the facility failed to notify the Ombudsman of resident transfers. This affected four (#14, #28, #43, #61) out of four residents reviewed for discharge notification. The facility census was 60. Findings Include 1. Resident #61 was admitted to the facility on [DATE] and she discharged to the hospital on [DATE]. Her diagnoses included muscle weakness, dysphasia, diabetes mellitus 2, congestive heart failure, osteoarthritis, essential primary hypertension, peripheral vascular disease, cerebral infarction, hyperlipidemia, anemia, chronic obstructive pulmonary disease, schizoaffective disorder, hypothyroidism, major depressive disorder, bullous disorder, chronic ischemic heart disease, anxiety disorder, fibromyalgia, anxiety disorder, acute kidney failure, irritable bowel syndrome, sleep apnea, gastro-esophageal reflux disease, and history of COVID-19. Review of the minimum data set (MDS) assessment, dated 12/31/21, revealed Resident #61 scored a nine on her brief interview for mental status (BIMS) and this indicated she has impaired cognition. Further review of the MDS assessment revealed Resident #61 required extensive assistance from staff with bed mobility, dressing, toilet use, personal hygiene. She was totally dependent on staff for transfers and bathing. Resident #61 required supervision from staff with eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 9 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the nursing progress notes for Resident #61 was discharged to the hospital on [DATE]. Further medical record review for Resident #61 revealed there was no documented evidence the Ombudsman was notified of the hospital transfer. 3. Review of the medical record for Resident #28 revealed an admission date of 05/28/21. Diagnoses included repeated falls, lack of coordination, type 2 diabetes mellitus without complications and chronic obstructive pulmonary disease. Resident is her own responsible party. Review of the MDS assessment dated [DATE] revealed Resident #28 had intact cognition and required extensive assistance with one person physical assist for Activities of Daily Living (ADL's). Review of the nursing progress notes for Resident #28 was discharged to the hospital on [DATE]. Further medical record review for Resident #28 revealed there was no documented evidence the Ombudsman was notified of the hospital transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 10 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #28's medical record revealed she was admitted on [DATE]. Diagnoses included but not limited to repeated falls, lack of coordination, type 2 diabetes mellitus without complications, altered mental, major depressive disorder recurrent, and chronic obstructive pulmonary disease. Resident #28 is her own responsible person. Review of the MDS assessment dated [DATE] revealed Resident #28 to have intact cognition and required extensive assistance with one person physical assist for Activities of Daily Living, (ADL's). Record review of the electronic medical record revealed Resident #28 was discharged to the hospital on [DATE] via emergency medical transport. Further medical record review for Resident #28 revealed there was no documented evidence the resident received the bed hold notice. Interview on 04/11/22 at 2:01 P.M., revealed Resident #28 reported she went hospital in February 2022 for bowel problems. Resident #28 denies been given bed hold notice when discharged to hospital. Based on medical record review, staff and resident interviews and policy review, the facility failed to notify the resident and/or resident representative of a resident of bed hold days at the facility. This affected four (#14, #28, #43 and #61) out of four residents reviewed for discharge notification. The facility census was 60. Findings Include: 1. Resident #61 was admitted to the facility on [DATE] and she discharged to the hospital on [DATE]. Her diagnoses included muscle weakness, dysphagia, diabetes mellitus 2, congestive heart failure, osteoarthritis, essential primary hypertension, peripheral vascular disease, cerebral infarction, hyperlipidemia, anemia, chronic obstructive pulmonary disease, schizoaffective disorder, hypothyroidism, major depressive disorder, bullous disorder, chronic ischemic heart disease, anxiety disorder, fibromyalgia, anxiety disorder, acute kidney failure, irritable bowel syndrome, sleep apnea, gastro-esophageal reflux disease, and history of COVID-19. Review of the minimum data set (MDS) assessment, dated 12/31/21, revealed Resident #61 scored a 09 on her brief interview for mental status (BIMS) and this indicated she has impaired cognition. Further review of the MDS assessment revealed Resident #61 required extensive assistance from staff with bed mobility, dressing, toilet use, personal hygiene. She was totally dependent on staff for transfers and bathing. Resident #61 required supervision from staff with eating. Resident #61 was discharged to the hospital on [DATE] via emergency medical transport. Further medical record review for Resident #61 revealed there was no documented evidence the resident received the bed hold notice. 3. Review of medical record for Resident #14 admission date of 12/26/19 no memory impairment cognition modified independence. Diagnoses include congestive heart failure, type 2 diabetes, hypertension, reflux and contracture to left knee. The resident remained at the facility. Review of Resident #14's quarterly MDS dated [DATE] revealed the resident required extensive two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 11 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0625 assist for bed mobility, transfers, and independent for eating. Level of Harm - Minimal harm or potential for actual harm Record review of the electronic medical record revealed Resident#14 was hospitalized on [DATE] and 09/21/21. Further medical record review for Resident #14 revealed there was no documented evidence the resident received the bed hold notice. Residents Affected - Some 4. Review of Resident #43's medical record revealed the resident was admitted on [DATE] with a readmission on [DATE] from a hospital stay from 01/18/22 through 01/20/22. Diagnoses of epilepsy and seizures. Review of Resident #43 medical record revealed no documentation of Bed Hold Policy notice was given to resident before discharge to the hospital. Further medical record review for Resident #43 revealed there was no documented evidence the resident received the bed hold notice. Interview on 04/18/22 at 4:07 P.M. with the Business Office Manager (BOM) #02 confirmed the facility does not notify residents of their bed hold days upon discharge from the facility. BOM #02 confirmed there was no bed hold notice provided to Resident #14, #28, #43 and #61 at the time of the hospital transfers. Review of the facility policy titled, Transfer/Discharges Notification and Right to Appeal, dated 12/20, revealed the facility will notify a resident of discharge thirty days prior to discharge, or as soon as practical, to an impending discharge or transfer out of the facility. Further review of the policy revealed, The Resident's Rights to bed hold will be explained at this time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 12 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records and staff and resident interviews, the facility failed to ensure residents were invited to care conferences to allow them to provide input in their care. This affected two (#28 and #42) out of three residents reviewed for care conferences participation. Facility census was 60. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 05/28/21 with diagnoses including but not limited to encounter for surgical aftercare following surgery on the digestive system, altered mental status, repeated falls, lack of coordination, type 2 diabetes mellitus without complications Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. Review of the medical record for Resident #28 revealed there was no documentation of care conference. Interview with Resident #28 on 04/11/22 at 1:59 P.M., revealed she could not remember the last time she had participated or attended a care conference. Interview with Social Services Designee (SSD) #12 on 04/13/22 at 10:25 A.M. verified Resident #48 was not offered to participate in care conferences. Interview with MDS Coordinator #7 on 04/13/22 at 11:17 A.M., revealed care conferences were to be held at least once every three months. 2. Review of Resident #42's medical record revealed the resident was admitted on [DATE]. Diagnoses include psychosis, behavioral and emotional disorders, depression, anxiety, mood disorder, bipolar and multiple sclerosis. Review of Care Conference documentation revealed the last care conference was held for Resident #42 on 02/23/20. Further review of the medical record for Resident #42 revealed there were no quarterly or annual care conferences held. On 04/12/22 at 8:58 A.M. an interview with Resident #42 revealed they had never had a care conference since admission. Resident #42 stated they had been at the facility for over two years. Interview with Social Services Designee #12 on 04/13/22 at 10:25 A.M. verified Resident #42 was not offered to participate in care conferences. Interview with MDS Coordinator #7 on 04/13/22 at 11:17 A.M., revealed care conferences were to be held at least once every three months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 13 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 and staff interview, the facility failed to ensure care planned interventions were in place for prevention of falls/accidents. This affected one (#31) of three residents reviewed for falls. The facility census was 60. Findings: Review of medical record for Resident #31 revealed admission date of 07/15/15 with a brief interview mental status (BIMS) score of 14 indicating intact cognition. Diagnoses include rheumatoid arthritis, chronic obstructive pulmonary disorder, contracture, and insomnia. The annual minimum data set (MDS) dated [DATE] revealed extensive two assist for bed mobility, transfers, dressing, toileting and supervision for eating. Record review of the care plan revealed Resident #31 was at risk for falls/injury related to weakness, impaired mobility, contractures and non compliance with interventions for therapy evaluations and treatment. Interventions included bed in low position, call light and personal items within reach, resident to use call light prior to ambulation, perimeter mattress and fall mat to side of bed initiated 05/14/19. Record review of physician notes revealed an order for a fall mat to bedside on 03/16/20. Record review of progress note dated 08/02/22 revealed the nurse was notified by staff resident was was found on the side of his bed. The resident informed the nurse he must have fallen out of bed, there was no documentation the fall mat was in place. Record review of fall accident investigation dated 08/02/21 revealed the resident had fallen out of bed. The documented intervention was to ensure fall mat is in place each shift. Record review of the progress note dated 11/06/22 revealed the resident slid out of bed onto his knees. There was no documentation the mat was in place. Record review of fall accident investigation dated 11/06/22 revealed Resident #31 did not use his call light. The nurse assessment documented a bruise was found on the residents right knee. There was no documentation the fall mat was in place. The intervention was to remind resident to use call light and assist resident with appropriate bed positioning. Observation on 04/13/22 11:36 A.M. revealed there was no fall mat on the floor beside Resident #31's bed. This was verified with licensed practical nurse (LPN) #29 at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 14 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, observations and staff and resident interviews, the facility failed to ensure dialysis resident received meals before dialysis appointments. This affected one (#48) of one residents reviewed for dialysis. Facility census was 60. Residents Affected - Few Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/12/22 with diagnoses include protein-calorie malnutrition hypertensive heart, failure and with stage 5 chronic kidney disease or end stage renal disease, chronic diastolic (congestive) heart failure, dependence on renal dialysis, convulsions, hyperlipidemia, anemia in chronic kidney disease, type 2 diabetes with other circulatory complications, and type 2 diabetes mellitus with other diabetic ophthalmic complication. Resident #48 is his own responsible party. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review medical records revealed Resident #48 attends dialysis on Mondays, Wednesdays and Fridays from 6:00 A.M. to 12:00 P.M. Review physician orders April 2022 revealed Resident #48 has a order for Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Glargine) and an order to inject 20 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus. Review Plan of Care dated 03/16/22 revealed alteration in kidney function due to End Stage Renal Diseases (ESRD), evidenced by hemodialysis. Interventions included by not limited to meals, meds, and written communication form with review weights and changes in condition between dialysis provider and living center. Review meal intake from 03/15/22 to 04/13/22 revealed Resident #48 was not receiving meals before going to dialysis. There were no documentation of monitor meal intake on dialysis days on 03/23/22, 03/28/22, 03/30/22, 04/01/22, 04/06/22, 04/11/22, and 04/13/22. Review Medication Administration Record (MAR) for March 2022 revealed Resident #48's insulin was extremely low on his dialysis days or thereafter. On Monday, 03/14/22 his glucose was 60 at 6:00 A.M., at 11:00 A.M., and at 4:00 P.M., on Saturday, 03/19/22 his glucose was 77 at 6:00 A.M., and 92 at 11:00 A.M. On Friday, 03/25/22 his glucose was 62 and 61 at 11:00 A.M. On Wednesday, 03/30/22 his glucose was 68 at 6:00 A.M., 79 at 11:00 A.M., and 85 at 4:00 P.M. Observation on 04/11/22 at 2:28 P.M., revealed Resident #48 was eating a blueberry custard pie and drinking a 32 oz of diet Mountain Dew. Interview on 04/11/22 at 2:29 P.M., revealed Resident #48 reported he gets real hungry on his dialysis days because the kitchen is closed and he does not get anything to eat. Resident #48 reported his sugar drops low on his dialysis days. Resident #48 reported he has a snack drawer and the snacks come from the vending machine. Resident #48 reported sometimes it takes all day for his sugar to regulate because he has had no protein. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 15 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/13/22 at 12:23 P.M., revealed Licensed Practical Nurse (LPN) #28 reported she does not think Resident #48 eats before going to dialysis. LPN #28 reported she is not here when he goes to dialysis. LPN #28 reported Resident #48 eats well when he returns. Observation on 04/13/22 at 12:31 P.M., revealed Resident #48 was eating a bear claw with his head low. Resident #48 hands were shaking and he had sweating slowly dripping down the side of his face. Interview on 04/13/22 at 12:32 P.M., revealed Resident #48 reported his sugar dropped and he did not eat anything all day. Resident #48 was snacks from the vending machine to get his sugar up. Observation on 04/13/22 at 12:51 P.M., revealed Resident #48 received his lunch. Licensed Practical Nurse (LPN) #28 checked Resident #48's blood sugar levels, it was at 64. Resident #48 reported to LPN #28 that dialysis went well. Resident #48 tried to use his spoon but his hands were shaking so much he could not hold on to the spoon. LPN #28 asked Resident #48 if he needed any assistance with his meal and he yes. LPN #28 fed Resident #48 mashed potatoes, gravy and turkey, frozen sweet potato souffle, and a peanut butter sandwich. Interview on 04/13/22 at 1:00 P.M., revealed LPN #28 reported Resident #48 feeds himself and is very independent. But since he was not feeling well he needs to get his sugar levels up. LPN #28 denied giving Resident #48 meals before dialysis. LPN #28 stated He is gone when I arrive. The night shift would be responsible. Interview on 04/13/22 at 1:12 P.M., revealed DON reported Resident #48 should be receiving a packed breakfast before he leaves for dialysis. Observation on 04/13/22 at 1:15 PM DON asked Resident #48 if he has been receiving breakfast before leaving dialysis. Resident #48 stated, I have not received any meals before going to dialysis. LPN #28 checked Resident #38's sugar and it was at 68. Interview on 04/13/22 at 1:30 PM DON reported she has spoken to dietary services and Resident #48 will receive a packed breakfast before he goes to dialysis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 16 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff and resident interviews, the facility failed to ensure an assessment was completed regarding the use of bedrail's on a residents bed. This affected one (#14) out of three residents reviewed for the use of bedrail's. The facility census was 60. Findings include: Review of medical record for Resident #14 revealed admission date of 12/26/19 with no memory impairment cognition modified independence. Diagnoses include congestive heart failure, type 2 diabetes, hypertension, reflux and contracture to left knee. The quarterly minimum data set (MDS) dated [DATE] revealed extensive two assist for bed mobility, transfers, and independent for eating. Review of the care plan revealed Resident #14 has a physical functional deficit related to mobility impairment, and range of motion limitations. Interventions included assistance of one staff member with noted activities of daily living fluctuations. Record review revealed Resident #14 had intact cognition and was unable to get out on bed independently. There was no documentation the facility assessed for safety concerns of bilateral side rail use prior to trying of the right rail. Further review of Resident #14's medical record revealed there was no order, assessment and/or other documentation regarding the use of bedrail's. Interview and observation on 04/11/22 at 12:17 P.M. revealed Resident #14 was concerned the right bedrail was tied down and she was unable to use it to assist herself in turning. Resident #14 voiced frustration she had been able to assist herself to remain on her side by holding onto the bed rail. Observation revealed there were three black zip ties attaching the right bed rail to the frame of the bed. Interview on 04/13/22 at 1:53 P.M. with the Administrator revealed Resident #14's bed rail was tied down to avoid both bed rails being up which could cause the restraint of residents. The Administrator confirmed there have been instances where staff have cut the zip ties on the rails to use the bed rails. The Administrator confirmed there was no assessment, order or other documentation in Resident #14's medical record regarding the bed rails on the resident's bed. Interview on 04/13/22 at 2:11 P.M. with Regional Clinical Director #121 revealed there are side rails which can't be removed from some beds in the facility. Regional Clinical Director #121 explained if the bed rails have the controls integrated into them, they were zip tied to avoid the ability of staff or family to use them as a form of restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 17 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on personnel file review and staff interview, the facility failed to provide performance evaluations for state tested nursing assistants (STNA's). This affected one of five state tested nursing assistant employee files reviewed and had the potential to affect all 60 residents residing in the facility. Facility census was 60. Residents Affected - Many Findings include: Review of employee file for STNA #32 revealed a hire date of 05/21/18. Further review of the employee file revealed there was no annual performance evaluation. Interview on 04/18/22 at 11:00 A.M. with Specialty Payroll #26 verified there was no annual performance evaluation for STNA #32. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 18 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 observations, staff interviews, review of infection control logs, review of dishwasher logs and review of service invoices, the facility failed to ensure the dishwashing machine had the appropriate rinse temperature and chemicals to sanitize dishes. This had the potential to affect all 60 residents who receive food from the kitchen. The facility census was 60. Findings include: On 04/11/22 at 9:00 A.M. observation of the dishwasher in the dishwasher room revealed the dishwasher heat temperature was 148 degrees Fahrenheit (F) and the rinse temperature gauge did not move. Testing of the chemicals with the chemical strips revealed no chlorine was detected in the dishwasher. On 04/11/22 at 9:18 A.M. observation of the recommendations label located on the dishwasher revealed for Chemical Dishwasher the Final Rinse Minimum temperature is 120 degrees F with recommended being 140 degrees F. Wash tank minimum temperature is 120 degrees F with recommended being 140 degrees F. Minimum sanitizer required is 50 parts per million (PPM) of chlorine. On 04/11/22 at 9:15 A.M. an interview with Account Manager #124 stated the facility will hand wash all dishes and has a call out to Food Safety Company #1 to fix the chemicals. On 04/11/22 at 10:29 A.M. an interview with District Manager #125 stated dishwasher has been serviced by Food Safety Company #1 monthly. On 04/11/22 at 3:05 P.M. an interview with Dietary Manager #126 stated Food Safety Company #1 replaced a hose on the dishwasher. Dietary Manager #126 states will email the results upon receipt. Dietary Manager #126 tested chemicals which read 200 PPM of chlorine. On 04/12/22 at 1:02 P.M. an interview with Account Manager #124 stated the staff are testing the temperature of the rinse cycle every two hours until the new gauge is replaced. On 04/12/22 at 1:32 P.M. an interview with District Manager #125 verified the rinse temperatures were documented at 100 degrees F from 04/02/22 each meal through 04/11/22 lunch time. On 04/14/22 at 2:00 P.M. an interview with the DON verified all 60 residents receive meals from he kitchen. Review of Infection Control Logs from 04/21 to 04/22 revealed no food borne illnesses. Review of the Dish Machine Log for April 2022 revealed that from 04/02/22 through 04/11/22 for breakfast, lunch and dinner, the rinse temperatures are documented as 100 degrees F for each meal. Review of the Invoice from Mechanical Repairs #2 revealed the facility ordered rinse temperature gauge and will be installed when part arrives. Review of the Extra Service Request dated 4/11/22 12:05 P.M. revealed Food Safety Company #1 found a leak in the sanitizer tubing and the tubing was replaced. The PPM for chlorine was tested at 200 after the tubing was replaced. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 19 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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, observations, staff interview, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), the facility failed to implement infection control practices by ensuring staff wore appropriate personal protective equipment (PPE) to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 60 residents residing at the facility. The facility census was 60. Residents Affected - Many Findings include: 1. Medical record review for Resident #413 revealed an admission date of 04/08/22. Her diagnosis included hypertensive urgency, diabetes mellitus 2, fracture of upper end of right humerus, cerebral infarction, dysphagia, hypokalemia, congestive heart failure, anemia, pleural effusion, hyperlipidemia, irritable bowel syndrome, osteoarthritis, and depression. Review of the 5-day minimum data set (MDS) assessment, dated 04/12/22, revealed Resident #413 scored a seven on her brief interview for mental status (BIMS), this indicated she had impaired cognition. Further review of the MDS assessment for Resident #413 required extensive assistance from staff with bed mobility, eating, toilet use, and personal hygiene. Review of the immunization record for Resident #413 revealed the resident did was not vaccinated against the COVID-19. Review of the physician orders for Resident #413 revealed an order written on 04/13/22 dated for 04/08/22, requiring the resident to be in isolation droplet precautions. Observation on 04/14/22 at 3:49 P.M. revealed State Tested Nurse Assistant (STNA) #04 walked out of Resident #413 isolation room with a surgical mask below her chin and was not wearing an isolation gown, and no eye protection. STNA #04 stated she was grabbing a gown for the resident and walked back into Resident #413's room with no PPE on. Observed a sign hanging on Resident #413's room stating droplet precautions- anyone who enters the room must wear an N95, face shield and gown. Interview on 04/14/22 at 3:49 P.M. interview with STNA #04 confirmed she walked out of Resident #413's room and did not have a N95, isolation gown or eye protection and her surgical mask was below her chin. STNA #04 confirmed the sign hanging on Resident #413's room stated a N95, isolation gown, and face shield was required to enter Resident 413's room. STNA #04 confirmed she was wearing a surgical mask and it was resting below her chin. STNA #04 stated she forgot to apply the proper PPE because the Resident #413 doesn't really have COVID 19. STNA #04 stated she is not sure what quarantine isolation means. Interview on 04/14/22 05:23 P.M. the Unit Manager (UM) #30 confirmed the facility was not aware the Resident #413 was not vaccinated against COVID 19 upon admission to the facility. UM #30 stated the facility learned Resident #413 was not vaccinated and moved her to the quarantine isolation unit on 04/11/22. Interview on 04/14/22 at 5:15 P.M. with the Regional Nurse (RN) # 121 confirmed she was notified on 04/11/22 of Resident #413 being admitted on [DATE] and a non COVID-19 vaccination status. RN #121 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 20 of 21 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 365764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Health and Rehab 7300 McEwen Road Dayton, OH 45459 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the Admissions team dropped the ball because the care team would be notified and the unvaccinated COVID-19 resident would be placed in quarantine isolation. RN #121 confirmed the resident was moved to the quarantine isolation unit on 04/11/22. 2. Observation on 04/18/22 at 7:08 A.M. of licensed practical nurse (LPN) #500 was standing at the nurse's station on the memory care unit resident hallway with no mask on. Seated next to her at the nurse's station was STNA #499 with her mask below her chin. Interview on 04/18/22 at 7:10 A.M. with LPN #500 confirmed she was not wearing a mask while standing at the nurse's station in a resident care area. LPN #500 held up her medication cup with goldfish crackers and stated her mask was down because she was eating a snack. Interview on 04/18/22 at 7:10 A.M. with STNA #499 confirmed she was seated at the nurse's station on the memory care unit with her mask below her chin. Review of the facility policy, admission of Known or Suspected COVID-19, dated 09/23/20 stated, to ensure compliance with CDC guidelines while minimizing the chance for exposures. Further review of the policy revealed, isolate the patient in their room with the door closed. Review of information from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 09/10/21 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed healthcare professionals who care for residents with suspected or confirmed COVID-19 or SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365764 If continuation sheet Page 21 of 21