Health inspection·July 8, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure broken bathroom sink faucets in resident rooms, loose door handles to resident rooms, and missing tiles outside the therapy room were repaired to provide a homelike environment. This affected four resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on two of six halls and the public hallway outside the therapy room. The facility census was 84. Findings included: An observation on 07/01/2025 at 9:57 AM revealed an area in the hallway outside the therapy room had an approximately three feet (ft) by three ft area of missing tiles with red cones placed on each side of the missing tiles. An observation on 07/07/2025 at 8:59 AM revealed the floor in the hallway outside the therapy room continued to have missing tiles with red cones blocking each side. An observation on 07/01/2025 at 12:11 PM revealed the bathroom sink in room [ROOM NUMBER] the faucet was broken, it could not be turned on or off completely, and it had constant running water. An observation on 07/01/2025 at 12:38 PM revealed the bathroom sink in room [ROOM NUMBER] had constant running water and the faucet was broken. An observation on 07/01/2025 at 12:57 PM revealed the door handle to room [ROOM NUMBER] was loose and broken. An observation on 07/03/2025 at 8:59 AM and on 07/04/2025 at 2:23 PM revealed the door handle to room [ROOM NUMBER] was loose. During an interview on 07/07/2025 at 8:23 AM, the Maintenance Supervisor (MS) stated he did not have a written plan for repairs for the facility but kept a list in his head and tried to prioritize as things came up. The MS stated the facility needed a lot of repairs and he had not been able to keep up with all the repairs. The MS stated he had a plan to fix the floor in the hallway but had not had time to do it. The MS stated he had also completed a lot of repairs he had not documented. The MS stated he knew that as the supervisor he was supposed to also do the paper work but he said he could not keep up with everything. During an interview on 07/07/2025 at 10:45 AM, Housekeeper (HSK) #14 stated if she saw something that needed repaired while she was cleaning she would text her supervisor. HSK #14 stated she did not write it down anywhere. During an interview on 07/07/2025 at 10:47 AM, HSK #13 stated if she saw something that needed repaired she would tell her supervisor and she would tell maintenance. HSK #13 stated she had not written anything down. During a concurrent observation and follow-up interview and on 07/07/2025 at 10:50 AM, the MS stated their plan was to fix the area of the hallway outside the therapy room that week, but other issues had come up over the weekend, and he had to prioritize what needed to be fixed. Upon entering the bathroom in room [ROOM NUMBER] the MS stated the sink was leaking and agreed the resident would not be able to use the faucet because the handle was loose and the faucet could not be turned on or off completely. The MS confirmed the leaking sink in room [ROOM NUMBER] and stated his assistant was fixing it that day (07/07/2025). The MS stated he had replaced at least four door handles last week but was not aware the doorhandles for room [ROOM NUMBER] or room [ROOM NUMBER] needed to be fixed. During an interview on 07/08/2025 at 9:08 AM, the Interim Administrator stated she was not aware of the leaking faucets. The Interim Administrator stated all repairs should be reported to the MS in the work order program, and they should be fixed. Review of the facility policy titled Safe and Homelike Environment, dated 09/29/2022, revealed in accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. The policy also indicated at bullet point #1, the facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. Bullet point #3 noted housekeeping and maintenance services will be provided as (continued on next page) 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 07/08/2025 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 0584 necessary to maintain a sanitary, orderly, and comfortable environment.This deficiency represents non-compliance investigated under Complaint Number 1289599. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 07/08/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview, record review, facility document review, and facility policy review, the facility failed to prevent staff verbal abuse for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. During an interview on 07/05/2025 at 9:45 AM, the interim Administrator was notified by the survey team that Resident #25 reported being told to shut up by CNA #3. Review of a Teachable Moment form, dated 04/26/2025, documented by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. During an interview on 07/07/2025 at 2:15 PM, Resident #25 stated they felt relief and powerful to be able to tell what had occurred because of feeling helpless and powerless before. 2. Review of the medical record revealed the facility admitted Resident #66 on (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 07/08/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated CNA #3 had yelled at them. On 07/01/2025 at 2:49 PM, the survey team notified the interim Administrator and the DON that Resident #66 had alleged verbal abuse by CNA #3. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with Resident #66 about verbal abuse from an aide. She stated the allegation had already been investigated. During a follow-up interview on 07/05/2025 at 8:00 AM, Resident #66 stated when CNA #3 was their aide it made the resident feel angry, anxious, and teary-eyed, and it made the resident have panic attacks. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. During an interview on 07/04/2025 at 1:43 PM, RN #5 stated Resident #66 had issues with CNA #3 where the resident would be upset to the point of tears because of not wanting the aide. RN #5 stated the facility was aware of the issues with CNA #3 because she discussed the concerns with upper management and had written Teachable Moment forms and presented them to CNA #3 as well. She stated she had expressed her concerns with the ADON and DON. She stated she was informed CNA #3 had been investigated, the matter was addressed, and the CNA was cleared. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/05/2025 at 3:53 PM, the former Administrator stated he thought the issue Resident #66 had involving an aide was the resident was on a phone call and the aide came to provide care and asked if the resident wanted care to be provided at that time, but there was nothing significant about it. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility policy titled Abuse and Neglect-Clinical Protocol, revised 03/2018, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of (continued on next page) 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 07/08/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Residents Affected - Few 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 07/08/2025 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 interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse to the administrator and the state survey agency for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The census was 84. Findings include:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. Review of a Teachable Moment form, dated 04/26/2025, provided by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. She stated that once a Teachable Moment form was completed, she gave it to the Director of Nursing (DON), then the DON would provide it to the Human Resources (HR) Director. LPN #6 stated she contacted the Assistant Director of Nursing (ADON) for guidance about the incident with CNA #3. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025, indicated no (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 07/08/2025 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 report was made to the state survey agency regarding Resident #25. During an interview on 07/04/2025 at 3:45 PM, the DON stated if there was a complaint related to abuse or neglect, then the facility policy would be followed. She stated Teachable Moments were given by the nursing staff to address actions that needed to be stopped. The DON stated once she reviewed the forms, she addressed the issue with the staff member, and if she felt the nurse handled the situation, then the form went into the staff member's personnel file. She stated she was not aware of any other abuse concerns involving CNA #3. The DON stated upon review of CNA #3's personnel file it contained no Teachable Moment forms. The DON stated if she had been told that CNA #3 had told a resident to shut up then an investigation would have been completed because that would have been considered abuse. She stated that no investigation had been carried out previously regarding Resident #25 being told to shut up. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025 revealed no report was made to the state survey agency regarding Resident #25. During an interview on 07/04/2025 at 4:43 PM, the interim Administrator stated staff were trained and expected to report abuse to the Administrator as soon as it happened. She stated if a resident had been told to shut up, she would expect it to be reported and an investigation to take place. 2. Review of the medical record revealed the facility admitted Resident #66 on 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated that CNA #3 had yelled at them. On 07/01/2025 at 2:49 PM, the survey team notified the interim Administrator and the Director of Nursing (DON) that Resident #66 had alleged verbal abuse by CNA #3. The facility's self-reported incident list, for the timeframe from 07/01/2024 through 07/01/2025 revealed no report was made to the state survey agency regarding Resident #66. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with the resident about verbal abuse from an aide. She stated the resident had a service issue with the aide, therefore, she did not make a report to the state survey agency. During an interview on 07/05/2025 at 2:26 PM (continued on next page) 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 07/08/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete with the interim Administrator and the [NAME] President of Clinical Services, it was reported they did not report the allegation of verbal abuse involving Resident #66 because it had been investigated, but they could not find the investigation. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy revealed at bullet point #9 to investigate and report any allegations within timeframes required by federal requirements. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, revealed all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations. The policy revealed at bullet point #1 if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies, which included, the state licensing/certification agency responsible for surveying/licensing the facility. The policy revealed immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 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 07/08/2025 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 interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were investigated and failed to prevent further abuse by removing the emoployee from duty after an allegation of abuse. This affected two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated Certified Nurse Aide (CNA) #3 told them to shut up. Resident #25 stated their previous roommate needed a lot of assistance and CNA #3 came and took the roommate to the bathroom. CNA #3 was not stable with the resident's wheelchair as CNA #3 was bumping against the wall. Resident #25 stated once CNA #3 and the roommate made it to the bathroom it sounded like the roommate had fallen. Resident #25 stated they went to the bathroom door to ask what was going on and CNA #3 told Resident #25 to shut up. Resident #25 stated they felt it was unprofessional for CNA #3 to tell them to shut up. Resident #25 stated that CNA #3 should not have talked to them like that. Review of a Teachable Moment form, dated 04/26/2025, documented by Licensed Practical Nurse (LPN) #6, revealed CNA #3 was presented with a concern marked other. The concern indicated CNA #3 was argumentative with a resident and other staff. CNA #3 told a resident to Shut up. The form indicated CNA #3 refused to sign the document. The document was signed by Registered Nurse (RN) #5 and LPN #6. During a telephone interview on 07/04/2025 at 2:37 PM, LPN #6 stated Teachable Moments were used as a corrective action the staff were asked to sign, so staff saw them as a write-up. She stated a Teachable Moment was given to CNA #3 for arguing with a resident and telling the resident to Shut up. LPN #6 stated the resident was worried about their roommate and was not aware CNA #3 was in the bathroom with the resident when they were yelling back and forth with each other. She stated in the moment Resident #25 got loud first and was upset. She stated that once a Teachable Moment form was completed, she gave it to the Director of Nursing (DON), then the DON would provide it to the Human Resources (HR) Director. LPN #6 stated she contacted the Assistant Director of Nursing (ADON) for guidance about the incident with CNA #3. During a telephone interview on 07/04/2025 at 1:43 PM, RN #5 stated the facility staff were aware of the issues with CNA #3. RN #5 stated she had discussed issues with upper management about CNA #3. Another nurse witnessed the aide tell a resident to shut up. The other nurse wrote up a Teachable Moment, with RN #5 present when it was provided to CNA #3. She stated she addressed the same concerns with the ADON and the DON. RN #5 stated she was told that CNA #3 had been investigated for verbal abuse and was cleared. During an interview on 07/04/2025 at 3:17 PM, the ADON stated Teachable Moments would be written by the nurse who would review it with the staff member and then the individual signed it. She stated there was an allegation that CNA #3 told a resident to shut up. The ADON stated there was an internal investigation and Resident #25 stated they (the resident) said something they (the resident) should not have. The ADON stated she thought the DON and the former Administrator gave CNA #3 a written warning. She stated she would probably consider the comment that CNA #3 made towards Resident #25 to shut up to be abuse. The facility was unable to provide an investigation of verbal abuse towards Resident #25. Residents Affected - Few (continued on next page) 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 07/08/2025 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 Review of CNA #3's timesheet revealed she worked on 04/26/2025 (date of alleged abuse) from 6:52 AM to 7:16 PM and on 04/27/2025 from 7:28 AM to 7:23 PM. Review of the facility's daily assignment sheets revealed CNA #3 was assigned as the aide for Resident #25 on 04/26/2025, 04/27/2025, 05/10/2025, 05/11/2025, 05/18/2025, 06/21/2025, and 06/22/2025. During an interview on 07/04/2025 at 3:45 PM, the DON stated that if there was a complaint related to abuse or neglect then the facility policy would be followed. She stated Teachable Moments were given by the nursing staff to address actions that needed to be stopped. The DON stated that once she reviewed the forms, she addressed the issue with the staff member, and if she felt the nurse handled the situation, then the form went into the staff member's personnel file. She stated that upon review of CNA #3's personnel file it contained no Teachable Moment forms. The DON stated if she had been told CNA #3 had told a resident to shut up an investigation would have been completed because that would have been considered abuse. The DON verified no investigation had been carried out regarding Resident #25 being told to shut up. During an interview on 07/04/2025 at 4:43 PM, the interim Administrator stated if a resident had been told to shut up, she would expect it to be reported and an investigation to take place. During an interview on 07/05/2025 at 2:26 PM with the interim Administrator and the [NAME] President of Clinical Service verified the allegation involving Resident #25 had been investigated but they could not find the investigation due to not knowing where the former Administrator kept his files. 2. Review of the medical record revealed the facility admitted Resident #66 on 02/19/2025. The resident had a medical history that included a diagnosis of anxiety disorder. Review of the quarterly MDS assessment, dated 06/04/2025, revealed Resident #66 had intact cognition. Review of the care plan, initiated 03/04/2025 and revised on 03/31/2025, indicated the resident had behaviors that included yelling at staff when care was being provided. Interventions included staff to tell the resident what they were going to do before they began and to speak to the resident unhurriedly and in a calm voice. During an interview on 07/01/2025 at 2:13 PM, Resident #66 stated that CNA #3 had yelled at them. During an interview on 07/03/2025 at 3:20 PM, the interim Administrator stated she had a conversation with Resident #66 about verbal abuse from an aide. She stated the allegation had already been investigated. During an interview on 07/05/2025 at 10:41 AM, Resident #66 stated at the end of May (2025) CNA #3 yelled, argued, and raised her voice with the resident related to the schedule and the amount of time it took for CNA #3 to answer their call light. Resident #66 stated CNA #3 told them they needed to get their facts straight about the call light being on for over an hour and a half. Resident #66 stated CNA #3 yelled and flung her arms around. Resident #66 stated they asked CNA #3 to have the nurse come to the room and CNA #3 ignored them. Then after about five minutes she got RN #5 to come in the room. Resident #66 stated when RN #5 entered the room they (the resident) had a panic attack. Resident #66 stated CNA #3 had been in their room that day (07/05/2025) when the resident had initiated a call light. Resident #66 stated the DON was aware the CNA was in her room because the DON instructed CNA #3 to turn off the call light. The facility was unable to provide an investigation of verbal abuse towards Resident #66. During an interview on 07/03/2025 at 7:51 PM, CNA #10 stated that around the end of May or June 2025, Resident #66 told her CNA #3 had yelled at the resident. CNA #10 stated she informed LPN #8 and Resident #66 told LPN #8 what happened. She stated no upper management staff interviewed or asked her any questions about the incident or interviewed any other residents. During an interview on 07/04/2025 at 10:32 AM, LPN #8 stated Resident #66 told her CNA #3 had said some offensive things towards the resident and the resident desired not to have her as an aide. LPN #8 stated when the resident reported the issues with CNA #3 to her she contacted the Scheduler. She stated the Scheduler told her to write some things down but she forgot to do so. She stated she was told if a (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 07/08/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete resident had a complaint to report it to the Scheduler first then to the ADON, and then to the DON. LPN #8 stated she thought the Scheduler did something with the information she reported to her and thought CNA #3 was written up. During an interview on 07/05/2025 at 2:26 PM with the interim Administrator and the [NAME] President of Clinical Services they verified it was reported that the allegation involving Resident #66 had been investigated but they could not find the investigation due to not knowing where the former Administrator kept his files. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 04/2021, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy revealed at bullet point #9 to investigate and report any allegations within timeframes required by federal requirements. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 2001, revealed all reports of resident abuse are thoroughly investigated by facility management. The policy revealed investigating Allegations included 1. All allegations are thoroughly investigated. The administrator initiates investigations. 7. The individual conducting the investigation as a minimum a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. Interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. The policy revealed 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. 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 07/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and a review of the facility's policy, the facility failed to notify the Office of the State Long Term Care Ombudsman and failed to provide written bed-hold notices for two (Resident #22 and Resident #17) of two residents reviewed for hospitalization. The facility census was 84 Findings include: 1. Review of the medical record revealed the facility admitted Resident #22 on [DATE]. The resident had a medical history that included a diagnosis of multiple sclerosis. Resident #22's progress notes dated [DATE] at 12:00 PM indicated the resident was transferred to the emergency room (ER) for an evaluation and treatment. Resident #22's progress notes dated [DATE] at 10:38 PM that indicated the resident returned to the facility from the hospital at 7:30 PM. Resident #22's progress notes dated [DATE] at 11:51 PM indicated the resident's family member called emergency medical services (EMS) due to suspecting the resident was having a stroke. The note revealed EMS took the resident to a local hospital. A progress note dated [DATE] at 12:31 AM indicated the resident remained in the hospital. Resident #22's progress notes dated [DATE] at 8:13 PM indicated the resident refused further medication for treatment of a new onset of pain and was adamant about being sent to the hospital. Resident #22's progress notes dated [DATE] at 7:40 AM indicated the resident was being admitted to the hospital. Resident #22's medical record revealed no documented evidence that the facility provided the resident/resident's family with a bed hold notice or notified the Ombudsman for the resident's hospitalizations on [DATE], [DATE], and [DATE]. Interview on [DATE] at 9:09 AM, Registered Nurse (RN) #20 stated she had only sent monthly notifications to the Ombudsman for residents that discharged home or discharged to other facilities. She stated she did not send monthly notifications for discharges to the hospital. She verified Resident #22's name was not on the monthly lists sent to the Ombudsman. Interview on [DATE] at 1:28 PM, Registered Nurse (RN) #20 stated they looked in the Business Office Manager's (BOM) office and could not find bed holds notices. Interview on [DATE] at 12:32 PM, Social Worker (SW) #19 stated she ran a report of resident discharges at the beginning of each month and emailed the report to the Ohio State Ombudsman and the [NAME] County Ombudsman. SW #19 stated she had only been sending them discharge information that included residents who left against medical advice (AMA), discharged home or to another facility, or were deceased . She stated that she was not aware until a few days prior she was supposed to send the Ombudsman a notification when a resident was hospitalized . Interview on [DATE] at 4:22 PM, the Director of Nursing (DON) stated that the BOM was responsible for completing bed hold notices. However, the DON stated she did not believe the BOM was sending the notices because they could not find any documentation. The DON stated the Social Worker was responsible for sending notifications to the Ombudsman. (continued on next page) 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 07/08/2025 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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 4:33 PM, the Administrator stated she was not sure whether social services staff or the BOM was responsible for sending the notifications to the Ombudsman and was not sure of the facility's process. The Administrator stated the BOM should have been sending bed hold notices to the hospital with the resident when they were transferred. Review of the facility policy titled Transfer or Discharge, Facility Initiated, revised 10/2022, revealed under the section titled, Notice of Transfer or Discharge (Emergent or Therapeutic Leave), included 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g. [exempli gratia, for example], in a monthly list of residents that includes all notice content requirements). 5. Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer. 2. Review of the medical record revealed the facility admitted Resident #17 on [DATE]. The resident had a medical history that included a diagnosis of acute and chronic respiratory failure with hypercapnia. Resident #17's progress notes dated [DATE] indicated the resident requested to be sent to the ER and was sent to the hospital via EMS. Resident #17's progress notes dated [DATE] indicated the resident was readmitted to the facility. Resident #17's progress notes dated [DATE] indicated the resident was transferred to the hospital for an evaluation after a fall. Resident #17 returned to the facility on [DATE]. Resident #17's progress notes dated [DATE] that indicated a nurse practitioner sent the resident to the ER due to decreased arousal and level of consciousness. The resident returned to the facility on [DATE]. There was no documented evidence the facility provided Resident #17 with a bed hold notice or the Ombudsman was notified when the resident was transferred to the hospital on [DATE], [DATE], and [DATE]. During an interview on [DATE] at 8:28 AM, the DON stated the business office staff were responsible for issuing bed hold notices when a resident went to the hospital. However, she stated they were not able to find any bed hold notices for Resident #17 when the resident was hospitalized . The DON stated social services staff were responsible for notifying the Ombudsman when residents went to the hospital and stated she did not know whether the Ombudsman was notified of Resident #17's hospitalizations. During an interview on [DATE] at 9:08 AM, the Administrator stated the Social Worker, or the DON should provide a bed hold notice when the resident was being discharged to the hospital, unless it was in the middle of the night; then the nurse should provide the notice. She stated that if the resident did not get a notice when discharged /transferred, the admissions staff should deliver the notice to the resident. The Administrator stated they could not locate bed hold notices for Resident #17. She stated that social services staff should be responsible for notifying the Ombudsman. 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 07/08/2025 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 record review, interview, and facility policy review, the facility failed to revise a care plan for one (Resident #19) of one resident reviewed for tube feedings. The facility census was 84. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included multiple sclerosis and oropharyngeal dysphagia (a disorder or impairment in initiating a swallow). Review of the Minimum Data Set assessment, dated 04/17/2025, revealed Resident #19 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem. The MDS indicated the resident had a feeding tube while they were a resident at the facility. Resident #19's current physician orders included an order dated 01/02/2025 for nothing by mouth (NPO) diet and enteral feeding of 2calorie formula at 60 milliliters (ml) an hour continuously with a 50 ml an hour fluid flush every shift with a 1320 ml total based on a 22-hour runtime. Review of Resident #19's care plan initiated 8/17/2021 identified the resident was at risk for malnutrition. Interventions directed staff to honor food preferences within scope of diet (initiated 01/11/2022); monitor/document/report as need any signs and symptoms of dysphagia to include holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals (initiated (01/11/2022); provide supervision, encouragement, cueing, or assist as needed to complete meals (initiated 08/17/2021); provide/serve diet as ordered, monitor intakes and record every meal, and report consistently poor intake to the dietitian (initiated 01/11/2022); and serve altered texture diet as ordered (initiated 08/17/2021). The Care Plan Report was revised to indicate the resident had a feeding tube placed on 06/19/2023. Interventions directed staff to elevate the head of the bed to 30 degrees while the tube feeding was running (initiated 06/22/2023); provide fluid flushes as ordered (initiated 06/22/2023); and provide tube feed as ordered (initiated 06/22/2023). The care plan was not revised to identify the resident's NPO status. During an interview on 07/05/2025 at 12:34 PM, the Corporate MDS Coordinator stated the facility did not currently have an MDS Coordinator, so she and another corporate person had been coming in for the last month or so to do the MDSs and care plans. She stated any acute changes to the care plan could be completed by the nursing staff. The care plan was reviewed quarterly, annually, and with any significant change to ensure it was up to date and accurate. She stated that if a resident was changed to being strictly NPO then the old interventions regarding oral intake should be resolved. During another interview on 07/05/2025 at 1:15 PM, the Corporate MDS Coordinator verified Resident #19's care plan had interventions that indicated to provide the diet as ordered. She stated Resident #19 was NPO with no pleasure feedings, so the care plan should have reflected that and that the resident was not receiving meals. During an interview on 07/08/2025 at 8:28 AM, the Director of Nursing (DON) stated the care plan should be updated by nursing staff. She verified the interventions regarding the oral intake should have been removed for Resident #19. During an interview on 07/08/2025 at 9:08 AM, the Interim Administrator stated the care plan should have been revised to reflect that Resident #19 was not taking anything by mouth. She stated it should have been done at the time the resident received an order to be NPO. It also should have been caught when reviewed quarterly. Review of facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/2022, revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the (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 07/08/2025 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 required quarterly MDS [Minimum Data Set] assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 07/08/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure medications and opened insulin vials were discarded when expired in two (Roosevelt, [NAME]) of four medication carts observed. The facility census was 84. Findings include: An observation on 07/03/2025 at 1:15 PM of the Roosevelt medication cart revealed a bottle of fish oil that contained 115 tablets, with an open date of 11/01/2024 and an expiration date of 04/2025. The medication cart revealed a vial of Humalog 100 units/milliliter (ml) insulin with an opened date of 05/24 (month/day). An observation on 07/03/2025 at 1:25 PM of the [NAME] medication cart with Licensed Practical Nurse (LPN) #22 revealed a vial of Humalog 100 units/ml with an open date of 05/27 (month/day). During an interview on 07/03/2025 at 1:20 PM, LPN #22 stated insulin was to be used within 28 days of being out of the refrigerator and opened. She stated staff were trained and expected to check for expired medication and dates when medications were opened. During an interview on 07/05/2025 at 12:52 PM, the DON stated Humalog vials were good for 28 days once opened, and expired supplies were the responsibility of everyone. The DON stated staff were trained and expected not to use expired medications. Review of a facility policy titled Medication Labeling and Storage, revised 02/2023, revealed in the section titled Medication Storage, if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The policy revealed the section titled Medication Labeling, included Multi-dose vials that have been opened or accessed (e.g. [exempli gratia, for example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 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 07/08/2025 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacturer's guidelines, the facility failed to obtain laboratory tests as ordered by the physician for one (Resident #10) of five residents reviewed for unnecessary medications. Additionally, the facility failed to ensure expired blood glucose monitoring strips were discarded in four (Roosevelt, [NAME], [NAME], Jefferson) four medication cars observed. The facility census was 84. Findings include:Review of the medical record revealed Resident #10 admitted on [DATE]. Diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy, hypertension, and atherosclerotic heart disease (ASHD) of native coronary artery without angina pectoris. Resident #10's care plan included a focus area initiated [DATE] that indicated the resident had a potential for alteration in hydration related to diabetes mellitus, potential for alteration in blood glucose due to insulin dependent diabetes mellitus, and impaired cardiovascular status related to ASHD and hypertension. Interventions directed staff to obtain and monitor lab/diagnostic work per physician order. Resident #10's physician orders included an order with a start date of [DATE] for ammonia level and hemoglobin A1c every 90 days for monitoring. An order with a start date of [DATE] included a complete blood count (CBC), comprehensive metabolic profile (CMP), and hepatic panel every 180 days for monitoring. Resident #10's electronic health record (EHR) revealed no laboratory (lab) results for the ammonia level ordered to be completed in [DATE] and [DATE] and no laboratory results for the CMP or CBC ordered to be completed in [DATE]. During an interview on [DATE] at 3:33 PM, the Director of Nursing (DON) stated they did not have the resident's lab results for the ammonia level for [DATE] or [DATE], or for the CMP and CBC for [DATE]. She stated they had a new physician group that started in January (2025), and they marked everything on the standing order list. However, when they actually came into the building they indicated that they did not want the routine labs to be done, but she forgot to go in and discontinue the orders. During an interview on [DATE] at 8:28 AM, the DON stated the nurse, or the provider, would put in the orders for labs. The nurse should then take off the order, put the order in the lab portal, and schedule it through the portal. She stated the order would show up on the treatment administration record and the third shift should print off the requisition and the list of everyone who gets a lab drawn that day. She stated she ran a list every day to see what orders had not been completed. She stated they also had a direct link to the lab. She stated nursing was responsible for following up on the labs. The DON stated the order for Resident #10's labs should have been discontinued. She stated it was an issue from when they switched from the old provider to the new provider. She stated she did not know if the provider was notified. 2. Review of the manufacturer guidelines for Assure Platinum Test Strips, revised 12/2023, revealed when the vial is first opened, write the date on the vial label. Use the test strips within three months of first opening the vial. An observation on [DATE] at 1:15 PM of the Roosevelt medication cart revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. An observation on [DATE] at 1:25 PM of the [NAME] medication cart with Licensed Practical Nurse (LPN) #22 revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. During an interview on [DATE] at 1:20 PM, LPN #22 stated she had no idea that glucose test strips were to be used within 90 days of opening. She stated staff were trained and expected to place dates on the test strips when they were opened. An observation on [DATE] at 1:30 PM of the [NAME] medication cart with Registered Nurse (RN) #7 revealed two open bottles of Assure Platinum blood glucose test strips with no date as to when it was opened. During a concurrent interview, RN #7 stated staff were trained and expected to check that a date was written on the outside of the blood glucose test strip Residents Affected - Some (continued on next page) 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 07/08/2025 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete bottle when opened. An observation on [DATE] at 1:32 PM of the [NAME] medication cart revealed one open bottle of Assure Platinum blood glucose test strips with no date as to when it was opened. During an interview on [DATE] at 1:35 PM, LPN #6 stated staff were trained and expected to check the bottles for a date on them when opened. During an interview on [DATE] at 12:52 PM, the Director of Nursing (DON) stated expired supplies were the responsibility of everyone. She stated she was not aware the blood glucose test strips were only good for 90 days. The DON stated staff were trained and expected not to use expired supplies and to date the glucose test strips (when opened). 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 07/08/2025 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 observation, interview, facility document review, and policy review, the facility failed to maintain the food prep areas in a sanitary manner, failed to ensure proper setup of the three-compartment sink; and failed to complete daily temperature logs for the dish machine. This affected all residents who received food from the kitchen. The facility census was 84.Findings include: Observations on 07/01/2025 at 9:34 AM, during an initial tour of the kitchen, revealed excessive accumulation of dust was observed on the ceiling vent above the food preparation table near the stove. Dietary Aide (DA) #2 was prepping burgers on the food preparation table. A pan of six burgers was observed sitting on the food preparation table underneath the ceiling vent. There was black buildup and excessive accumulation of dust on the ceiling vents above the food preparation table near the walk-in freezer. The ceiling paint was observed to be peeling above the food preparation table near the walk-in freezer. There was an excessive buildup of dust on a ceiling vent located directly above the drying rack where clean dishes were stored in the dishwashing room. The three-compartment sink was observed to not be properly set up. The first compartment was empty. The second compartment, which was designated for rinsing only, was filled with dishwater containing visible detergent suds. The third compartment, designated for sanitizing, contained water with a sanitizing solution. DA #2 was observed washing the dishes in the second compartment, placing the dishes into the third compartment, and then placing the dishes on a cart next to the third compartment to dry. DA #2 stated he was not using the first compartment of the three-compartment sink because it was clogged with trash. An observation on 07/03/2025 at 11:05 AM revealed there was an excessive buildup of dust on a ceiling vent located directly above the drying rack where clean dishes were stored in the dishwashing room. Interview on 07/04/2025 at 1:00 PM, DA #2 stated the sink had been clogged for at least eight months. He stated all three compartments were clogged, but the first compartment was the worst. DA #2 stated he had been trained on how to set up the three compartment sink. A Dish Machine Log, dated 03/2025, revealed no documentation of dishwashing temperatures and parts per million (ppm) for the chemical sanitizer on 03/14/2025 and 03/31/2025 for lunch and dinner services. On 03/15/2025, 03/21/2025, 03/22/2025, 03/24/2025, 03/25/2025, 03/26/2025, 03/28/2025, and 03/29/2025 for breakfast, lunch, and dinner services. On 03/16/2025 through 03/20/2025, 03/23/2025, 03/27/2025, and 03/30/2025 for dinner services. A Dish Machine Log, dated 04/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 04/06/2025, 04/08/2025 through 04/11/2025, 04/13/2025, 04/14/2025, 04/16/2025, 04/18/2025, 04/20/2025, 04/22/2025, 04/24/2025, 04/25/2025, 04/28/2025, and 04/30/202, for the dinner services. A Dish Machine Log, dated 05/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 05/01/2025, 05/04/2025 through 05/09/2025, 05/11/2025, 05/13/2025, 05/14/2025, 05/19/2025 through 05/22/2025, 05/26/2025 through 05/29/2025, and 05/31/2025 for dinner services. On 05/02/2025, 05/03/2025, 05/17/2025, 05/18/2025, and 05/30/2025 for breakfast, lunch, and dinner services. On 05/10/2025, 05/15/2025, 05/16/2025, 05/24/2025, and 05/25/2025 for lunch and dinner services. A Dish Machine Log, dated 06/2025, revealed no documentation of dishwashing temperatures and ppm for the chemical sanitize on 06/01/2025, 06/20/2025, and 06/21/2025 for breakfast, lunch, and dinner services. On 06/06/2025, 06/07/2025, and 06/27/2025 for breakfast and lunch services. On 06/13/2025, 06/14/2025 for lunch and dinner services. On 06/12/2025 and 06/15/2025 for dinner services. On 06/19/2025 and 06/05/2025 for lunch services and on 06/05/2025 for breakfast services. Interview on 07/04/2025 at 1:08 PM, the Dietary Manager (DM) stated staff should be documenting temperatures and the ppm for the chemical sanitizer levels three times a day at breakfast, lunch, and dinner. The DM stated the dish washers (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 07/08/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete were responsible for documenting the temperatures on the Dish Machine Log. The DM stated he could not find a Dish Machine Log for January (2025). He stated maintenance staff would be responsible for cleaning the ceiling vents and scraping the paint on the ceiling when he reported the concern to him. He stated he usually reported concerns to maintenance staff verbally or by email. The DM stated he did not know the last time the ceiling vents were cleaned but needed to be clean because of the possibility of contamination. The DM stated that the second compartment on the three-compartment sink was used for rinsing, the first compartment was used for washing, and the last compartment was used for sanitizing. He stated just washing and sanitizing was not correct. The dishes should be rinsed with clean water and placed in sanitizer for at least sixty seconds. He stated DA #2 seemed to think the sink was clogged, but the compartment could be used. Interview on 07/07/2025 at 3:39 PM, the DM stated he was made aware of the sink being clogged the night before the survey started. He stated he thought it was coffee grounds clogging the sink. The DM stated he reported it to the Maintenance Director as soon as DA #2 reported it to him and the sink was repaired. Review of the facility policy titled Sanitization, revised 11/2022, revealed, manual washing and sanitizing is a three-step process for washing, rinsing, and sanitizing: a. Scrape food particles and wash using hot water and detergent; b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water (at least 171? [degrees Fahrenheit] for 30 seconds) or chemical sanitizing solution. Chemical sanitizing solutions (e.g. [exempli gratia, for example], chlorine, iodine, quaternary ammonium compound) are used according to manufacturer's instructions. Event ID: Facility ID: 365764 If continuation sheet Page 21 of 21