Health inspection·July 31, 2024

F 0689 nondisplaced fracture versus prior trauma. Level of Harm - Actual harm Review of progress note for Resident #66 dated 06/03/24 timed at 9:55 P.M. revealed the nurse spoke with the on-call physician and received an order for the resident to follow up with an orthopedic doctor and to wear a sling due to left humerus fracture. Residents Affected - Few Review of investigation file for Resident #66 regarding the incident dated 06/03/24 revealed on 06/03/24 at 4:00 P.M. when two STNAs transferred the resident to bed without use of a Hoyer lift the resident reported she heard a pop to her left arm and shoulder area. Review of the witness statement per STNA #187 dated 06/03/24 revealed Resident #66 was in her shower chair and began to complain the shower chair was cutting into her butt, so she pushed the resident to her room in the shower chair. Further review of the statement revealed the Hoyer lift was not working, so STNAs #187 and #188 manually transferred the resident to bed. Then Resident #66 complained of hearing a pop to her left shoulder area. Review of the witness statement from STNA #188 dated 06/03/24 revealed STNA #187 and #188 transferred Resident #66 from the shower chair to the bed with STNA #188 holding the resident's legs and STNA #187 holding the resident's chest. Interview on 07/24/24 at 1:06 P.M. with Resident #66 confirmed she had a broken left upper arm that occurred after two STNAs failed to use a Hoyer lift last month to transfer her. Interview confirmed the Hoyer battery was dead when they attempted to use it, so they picked the resident up and put her in bed. Resident #66 further confirmed during the transfer she told the aides she heard and felt something pop in her left arm. Interview on 07/25/24 at 3:15 P.M. with STNA #188 confirmed on 06/03/24 she assisted STNA #187 with a transfer of Resident #66 from the shower chair to the bed. STNA #188 confirmed they were supposed to use a Hoyer lift to transfer the resident, but the lift wasn't working so they manually transferred the resident. STNA #188 confirmed she picked up the resident by her legs and STNA #187 picked up the resident by her chest. STNA #188 confirmed Resident #66 reported she heard a pop in her left shoulder area during the transfer. Interview on 07/25/24 at 4:11 P.M. with the Director of Nursing (DON) confirmed STNAs #187 and STNA #188 manually transferred Resident #66 from the shower chair to the bed 06/03/24 at 4:00 P.M. when the Hoyer lift was not working. The DON confirmed Resident #66 had a physician's order to be transferred via Hoyer lift only. The DON confirmed Resident #66 sustained a fracture to the left humerus during the manual transfer on 06/03/24. Interview on 07/31/24 at 2:02 P.M. with the Administrator confirmed he was not aware of the manual transfer of Resident #66 on 06/03/24 in which the resident sustained a broken humerus. Review of the facility policy titled Mechanical Lifts and Transfer undated revealed safety was a primary concern for residents, staff and visitors. The use of mechanical lifts required a competent and skilled user and required the use of two employees to perform the lift safely, for both the resident and the employees. This deficiency represents noncompliance investigated under Complaint Number OH00155630. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #169) of three residents reviewed for medication administration. The facility census was 169 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #169 revealed an admission date of 07/18/24 with diagnoses of chronic obstructive pulmonary disease and pressure ulcer of sacral region. Review of the preadmission paperwork from Resident #169's prior skilled nursing facility dated 07/18/24 revealed the resident was to receive the following medications: aspirin 81 milligrams (mg) once daily, lisinopril 10 mg at bedtime for hypertension, hold if systolic blood pressure was less than 110 or if pulse was less than 60, methocarbamol 750 mg every six hours. Review of the admitting physician's orders for Resident #169 dated 07/18/24 and transcribed from the preadmission paperwork provided by the resident's previous facility revealed the order for aspirin was omitted and was not transcribed. The lisinopril order did not include the parameters to hold the medication for systolic blood pressure less than 110 or pulse less than 60. The methocarbamol order was transcribed as being given as needed every six hours instead of being given routinely every six hours. Review of the Medication Administration Record (MAR) for Resident #169 dated July 2024 revealed the resident did not receive aspirin 81 mg from 07/18/24 through 07/31/24. Lisinopril was administered from 07/18/24 to 07/24/24 but did include a blood pressure and/or pulse check prior to administration. The parameters to hold lisinopril for systolic blood pressure less than 110 or pulse less than sixty were added on 07/25/24. Methocarbamol was given as needed and not every six hours as ordered from 07/18/24 to 07/31/24. Interview on 07/31/24 at 10:20 A.M with Licensed Practical Nurse (LPN) #171 confirmed Resident #169 had an order for aspirin 81 mg once daily that was omitted on admission. Interview further confirmed the parameters to hold lisinopril were not transcribed upon admission but were added on 07/25/24. LPN #171 further confirmed methocarbamol was transcribed as an as needed medication but was supposed to be given every six hours routinely. LPN #171 confirmed Resident #169's medical record did not include documentation the physician was notified of the orders and/or that the physician had ordered any changes to the medications received in the admission orders from the prior skilled nursing facility. Interview on 07/31/24 at 12:58 P.M. with LPN #234 confirmed he completed the admission orders for Resident #169 based on the orders sent to the facility from the prior skilled nursing facility order summary. Interview confirmed he called the physician prior to admission to confirm the orders and the physician had made no changes. LPN #234 confirmed he thought he had transcribed the admission orders correctly but confirmed he made the following errors: the order for the aspirin was omitted, the parameters for lisinopril administration were not entered, methocarbamol was transcribed as an as needed medication instead of a routine medication. Review of the facility policy titled Medication Administration revealed medications should be administered only as prescribed by the provider. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405 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 0760 This deficiency represents noncompliance investigated under Complaint Number OH00156006. 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: 365877 If continuation sheet Page 4 of 4