Inspection·October 27, 2025

F 0550 non-compliance investigated under Complaint Number 2643951. 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: 365821 If continuation sheet Page 2 of 4 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 365821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, resident and staff interviews, review of facility Self-Reported Incidents (SRIs) and investigation, and policy review, the facility failed to ensure staff immediately reported allegations of abuse to administration and failed to complete a thorough investigations into allegations of abuse. This affected two (#34 and #105) of five residents reviewed for abuse. The facility census was 103.Findings include: Review of the medical record for Resident #34 revealed an admission to 08/30/24 with medical diagnoses of Parkinson's disease, chronic obstructive pulmonary disease (COPD), and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Resident #34 was always incontinent with bladder and bowel. Review of the facility's SRI number 265729 and investigation, dated 09/26/25 at 5:08 P.M., revealed on 09/25/25 at 7:30 P.M., Resident #34 stated Certified Nursing Assistant (CNA) #210 failed to provide cares/services for Resident #34 as requested. Resident #34 stated he felt he had been mistreated. Review of an Employee Reporting Form, completed by Registered Nurse (RN) #215, revealed a statement by Resident #34 reported CNA #210 had been very aggressive when putting him into bed via mechanical lift. Resident #34's stated once in bed, CNA #210 told Resident #34 to turn to his left side which Resident #34 was unable to do independently. Per Resident #34's statement, CNA #210 then informed Resident #34 Well I ‘ain't' helping you and left the room with the mechanical lift pad still under Resident #34 and never returned. Per the Employee Reporting form, CNA #210 had been implicated in other situations and received verbal warnings. The statement from CNA #210 that was obtained via text message which stated CNA #210 and a coworker (unidentified) had put Resident #34 back to bed via mechanical lift and CNA #210 had to go back to the memory care unit for the next 12 hours. No other information was noted in CNA #210's statement about the allegation. The facility's investigation did not include Resident #34's roommate (#33) statement to see if he witnessed the incident and did not include other residents who may have witnessed it and/or have concerns with CNA #210. The investigation did not include any staff statements from other staff who worked the same shift on 09/25/25. The investigation did not have a witness statement from the coworker who CNA #210 stated assisted with the transfer of Resident #34. Interview on 10/21/25 at 9:11 A.M. with Resident #34 stated a CNA (#210) with blue hair, had changed his clothes, assisted him back to bed via mechanical list, and had changed his incontinence brief. Resident #34 stated CNA #210 then told him to roll to his left side which Resident #34 stated he was unable to do independently. Resident #34 stated CNA #210 got mad at him because he couldn't roll and then CNA #210 left the room with Resident #34 in the bed with his incontinence brief open and mechanical lift pad underneath his body. Resident #34 stated he had to call out to get someone else to help him. Interview on 10/21/25 at 10:46 A.M. with RN #215 stated she was informed on 09/26/25 during morning report that a CNA (unidentified) on 09/25/25 had made an allegation of neglect against another aide (CNA #210). RN #34 confirmed the residents described CNA #210, the aide with the blue hair. RN #215 confirmed the allegation of neglect was not immediately reported to Administrator or supervisor on 09/25/25. RN #215 stated she obtained a statement from Resident #34 on 09/26/25 who stated the incident occurred on 09/25/25. Interview on 10/21/25 at 10:56 A.M. with the Administrator confirmed investigation into the allegation of abuse for Resident #34 did not contain any witness interviews and the staff had not immediately reported the allegation of abuse on 09/25/25 until 09/26/25. Interview on 10/27/25 at 10:18 A.M. with the Director of Nursing (DON) confirmed SRI number 265729's investigation did not contain documentation to support witness statements were obtained. The DON also confirmed the allegation of abuse was not reported immediately to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365821 If continuation sheet Page 3 of 4 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 365821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Creek Nursing Center 5070 Lamme Road Kettering, OH 45439 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 Administrator or supervisor as per facility policy. 2. Review of the medical record for Resident #105 revealed an admission date of 09/23/25 with diagnoses including anemia, heart failure, chronic kidney disease stage III, atrial fibrillation, and myelodysplastic syndrome. Resident #105 was discharged on 10/10/25. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #105 was cognitively intact and required partial/moderate staff assistance with bathing, toilet hygiene, bed mobility, and transfers. Review of the facility's SRI number 265724 dated 09/26/25 at 4:34 P.M. stated on 09/25/25 at 9:00 P.M., Resident #105 was being assisted by CNA #211 and Licensed Practical Nurse (LPN) #220 and Resident #105 felt he was rushed with the mechanical lift transfer process and neither staff members were polite. Review of the SRI investigation revealed an Employee Reporting form, that was not dated, did not indicate who obtained Resident #105's statement, was not signed, and did not have any questions on the form answered. The form did contain documentation of a statement but did not indicate whose statement it was that said I was going to bed, I called and asked for help. I asked her to raise the bed, they tossed me in the bed and left me on the side of the bed, laying she didn't give me my call button, so I called out to see if anyone was in the hall. She came in and yelled. (It was unspecified which staff member and what exactly was yelled at to Resident #105), The facility's investigation did not include CNA #211 and LPN #220's witness statements. The investigation did not include any staff statements who worked the shift on 09/25/25. The facility's investigation did not include Resident #105's roommate statement and/or other residents to see if they witnessed the incident and/or have concerns with CNA #211 and/or LPN #220. Interview on 10/27/25 at 10:18 A.M. with the Director of Nursing (DON) confirmed SRI number 265724's investigation did not contain documentation to support witness statements were obtained. The DON also confirmed the allegation of abuse was not reported immediately to Administrator or supervisor as per facility policy. The DON also confirmed that the Employee Reporting form for SRI number 265724 did not contain the date/time, the name of the person who completed the form, the name of the person who provided the statement, or had any of the questions answered that were on the form. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property revealed the staff were to report all incidents/allegations of abuse immediately to the Administrator or designee. Once the Administrator and State Agency are notified, an investigation of the allegation violation will be conducted and completed within five working days. The investigation protocol included interviewing the resident, the accused, and all witnesses. The witnesses generally, including anyone who witnessed or heard of the incident, came in close contact with the resident the day of the incident (including other residents, family members) and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. This deficiency represents non-compliance investigated under Complaint Number 2643951. Event ID: Facility ID: 365821 If continuation sheet Page 4 of 4