Inspection·September 2, 2025

F 0565 Level of Harm - Minimal harm or potential for actual harm Council and provides assistance to the council such as correspondence. The facility documents the resident council meeting on the Resident Council Minutes form. Any concerns at the meeting should be documented on the Concern Form and distributed to the appropriate Department Head. The facility follows the Resident Grievance Procedure for any concerns identified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0574 The resident has the right to receive notices in a format and a language he or she understands. Level of Harm - Minimal harm or potential for actual harm Based on review of the Resident Council Minutes, and staff and resident interviews, the facility failed to ensure the residents had access to the state and local advocacy organizations. This affected three residents (#117, #59 and #128) and all residents residing on the South and [NAME] units. The census was 164.Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 revealed there was no evidence the state or local advocacy group contacts were reviewed at monthly Resident Council meetings. Observation on 08/07/25 at 2:30 P.M. of secured [NAME] and South units revealed no evidence of postings or available documents of state or local advocacy group contacts. Interviews with Residents #128, #59 and #117 during a surveyor led Resident Council Meeting on 08/05/25 at 2:06 P.M. revealed they did not know of any contact information of state or local advocacy groups. The residents stated in monthly Resident Council meetings, the state or local advocacy groups were not reviewed. The residents stated they would like to know the contact information and, in the past, had to ask staff for the contact information, which made them feel uncomfortable due to possible retaliation. Interview on 08/05/25 at 2:44 P.M. the Administrator confirmed the contact information of state or local advocacy groups were not documented on the monthly Resident Council meeting. The Administrator verified the contact information of state or local advocacy groups should be posted and available to residents on the secured units. Interview on 08/05/25 at 2:34 P.M. the Director of Nursing (DON) verified the contact information of state or local advocacy groups were not available on the secured [NAME] and South units. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations and staff and resident interviews, the facility failed to ensure a clean, comfortable, and homelike environment. This affected five (Residents #14, #36, #20, #65, and #112) of nine residents reviewed for environment. The facility census was 164.1.Review of the medical record for Resident #14 revealed an admission date of 11/25/24 with medical diagnoses of Parkinson's disease, schizophrenia, bipolar disorder, and hypertension. Review of the medical record for Resident #14 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #14 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers, and partial/moderate staff assistance with bathing. Observation and interview on 08/05/25 at 7:25 A.M. revealed water leaking from the toilet in Resident #14's bathroom onto the bathroom floor, floor in the room outside of bathroom, and to the threshold of the room to the hallway. Resident #14 stated the toilet had been leaking for several weeks and staff were aware. Interview on 08/05/25 at 7:35 A.M. with Housekeeping #609 confirmed the toilet in Resident #14's room was leaking water onto the bathroom floor, floor in the room outside the bathroom, and to the threshold of the room to the hallway. Housekeeping #609 confirmed the toilet had been leaking for “a while” and stated he would clean up the water right away. 2. Observations of the [NAME] Unit on 08/04/25 at 9:30 A.M. revealed the unit smelled like urine. At 2:06 P.M. the unit still smelled of urine. Observations on 08/06/25 at 7:40 A.M. and 12:02 P.M. the [NAME] Unit still smelled of urine. Observation of 08/07/25 at 9:00 A.M. the [NAME] Unit still smelled of urine. Interview with Housekeeping #602 on 08/07/25 at 9:07 A.M. confirmed the [NAME] unit smelled of urine. 3. Observation of the bathroom for Resident #36 on 08/04/25 at 11:57 A.M. revealed the light was hanging off the medicine cabinet with light socket exposed. The handle going into the bathroom was jiggly and about to fall off the door. Interview and observation of Resident #20's room on 08/04/25 at 12:42 P.M. revealed his room was dark and the lights were burned out in his overhead light. He had no lights in his room. The string to the light was short and the resident couldn't reach it. The resident stated the lights have been burned out for some time now and his string was not long enough for him to reach it. Interview and observation of Resident #65's room on 08/05/25 at 7:36 A.M. revealed the string to his light on the back wall behind his bed was short and the resident could not reach it because he was bed bound. There were gouges out of the wall behind his bed and to the side of it. There were missing hooks off his privacy curtain and the curtain is hanging in that area. The resident stated he doesn't get out of bed, and he isn't able to reach his light to be able to turn his light on and off from his bed because the cord wasn't long enough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Interview with the Maintenance Director #499 on 08/07/25 at 2:57 P.M. toured the above-mentioned rooms and confirmed the problems in the rooms. 4. Review of the medical record for Resident #112 revealed an admission date of 02/19/24. Diagnoses included dementia, anxiety disorder, and cerebrovascular accident. Residents Affected - Some Review of the MDS assessment dated [DATE] revealed Resident #112 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and dressing, and supervision with transfers. Observation on 08/04/25 at 1:38 P.M. revealed five gashes about 12 inches in length behind the headboard of Resident #112's bed. Interview on 08/07/25 at 9:10 A.M. with Maintenance Director #499 verified the gashes behind the headboard of Resident #112's bed. This deficiency represents non-compliance investigated under Complaint Numbers 1259570 and 2573764. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to timely report an allegation of resident to resident sexual abuse to the State Agency (SA). This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164.Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors.Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area.Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed.Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers.Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors.Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse.Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) revealed Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH).Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed.This deficiency represents non-compliance investigated under Complaint Numbers 1259568 and 1259561. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 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 review of medical records and staff interviews, the facility failed to timely investigate an allegation of resident to resident sexual abuse. This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164.Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors.Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area.Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed.Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.Review of the MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers.Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors.Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse.Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH).Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed. This deficiency represents non-compliance investigated under Complaint Numbers 1259568 and 1259561. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed accurately upon admission. This affected one (#07) resident out of two residents reviewed for PASARR. The facility census was 164.Review of the medical record for Resident #07 revealed an admission date of 10/18/24 with medical diagnoses of diabetes mellitus, hypertension, post traumatic stress disorder (PTSD), bipolar disorder, and chronic kidney disease. Review of the medical record for Resident #07 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/09/25, which indicated Resident #07 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, supervision with bed mobility and transfers, and set-up assistance with eating and bathing. Review of the medical record for Resident #07 revealed a PASARR dated 10/10/24 which revealed a diagnosis of panic or other severe anxiety disorder was documented. Review of the PASARR revealed no other mental health diagnoses were indicated. Review of PASARR notice dated 10/10/24 revealed there were no indications of serious mental health illness and/or developmental disability. Interview on 08/07/25 at 1:32 P.M. with the Administrator stated the Social Service department are to review all resident PASARRs upon admission to ensure all mental health medical diagnoses were included. The Administrator confirmed the PASARR for Resident #07 did not have documentation to support bipolar disorder. Review of the facility policy titled, Pre-admission Screening and Resident Review, stated a PASARR is a mandate of Omnibus Budget Reconciliation Act (OBRA) 1987 Nursing Home Reform Act while requires states to identify and evaluate all individuals admitted to Medicaid certified nursing facilities for evidence of Severe Mental Illness (SMI), Intellectual or Development Disabilities (ID/DD) or related condition to ensure needs are met in most appropriate setting. This prohibits nursing facilities from admitting or retaining an individual with SMI or ID/DD unless the individual requires level of services of a nursing facility (NF), receives adequate services to meet needs and is in the least restrictive setting. The policy stated all individuals must be screened for indications of serious mental illness and ID/DD unless they meet the requirements for a hospital discharge exemption regardless of pay type. The policy stated any new admission with inaccurate information (clean Level 1 and needs Level 2) will have a Resident Review initiated immediately by the social service or designee as assigned by the Executive Director. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to develop comprehensive care plans in a timely manner. This affected two (Residents #160 and #49) of 32 residents sampled for care plans. The census was 165. 1. Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors. Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area. Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed. Interview on 08/07/25 10:26 AM with MDS Nurse #426 verified Resident #49 was not care planned for inappropriate sexual behaviors. 2. Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven. This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers. Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors. Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse. Residents Affected - Few Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH). Interview on 08/07/25 10:24 AM with MDS Nurse #426 verified there was no care plan for Resident #160 for inappropriate sexual behaviors. Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed. Review of the policy titled Plan of Care Overview not dated, revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines and goals to potentially return to a community setting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, interviews with staff, residents, and family, review of video footage from electronic monitoring device, and policy review, the facility failed to provide adequate supervision to prevent two cognitively impaired residents (#49 and #160) from continuing to engage in sexually aggressive behaviors in the female resident's room (#160). This resulted in Immediate Jeopardy and the potential for serious, physical, mental, and/or psychosocial negative outcomes for two residents (#49 and #160) when the facility failed to supervise and intervene to prevent Resident #49 from entering Resident #160's room and engaging in sexual activity. On 04/28/25, Resident #49 entered Resident #160's room numerous times throughout the day. Resident #49 was observed touching Resident #160's breast outside the shirt and kissing her lips. After numerous times of Resident #49 entering and leaving Resident #160's room, the residents were observed engaging in oral sex on each other. At no time was staff observed checking on the residents or redirecting Resident #49 out of Resident #160's room from 9:42 A.M. to 3:28 P.M. At approximately 3:28 P.M., Licensed Practical Nurse (LPN) #491 and Certified Nursing Assistant (CNA) #436 walked into Resident #160's room where they found Resident #160 on her bed with her pants and depends on the ground and Resident #49 standing in front of her. Resident #49 was redirected out of the room. The facility failed to complete an investigation, failed to complete a Self-Reported Incident (SRI), and failed to initiate/update residents' care plans to address the sexually inappropriate behavior. This affected two (#49 and #160) of two residents reviewed for supervision. The facility census was 164. On 08/13/25 at 4:46 P.M., Regional Director of Operations (RDO) #750, the Director of Nursing (DON), and Divisional Director of Clinical Operations (DDCO) #751 were notified Immediate Jeopardy began on 04/28/25 when Resident #49 entered Resident #160's room at 9:42 A.M. and was observed touching her breast and kissing her lips. After numerous times of Resident #49 entering and leaving Resident #160's room, the residents were observed engaging in oral sex on each other. At no time was staff observed checking on the residents or redirecting Resident #49 out of Resident #160's room from 9:42 A.M. to 3:28 P.M. At approximately 3:28 P.M., Licensed LPN #491 and CNA #436 walked into Resident #160's room where they found Resident #160 on her bed with her pants and depends on the ground and Resident #49 standing in front of her. Resident #49 was redirected out of the room. The Immediate Jeopardy was removed on 08/14/25 when the facility implemented following corrective actions: On 04/28/25 at 3:28 P.M., CNA #436 was completing room rounds and went into Resident #160's room. Resident #160 was in bed with her pants to her knees. Resident #49 was in the room with clothes on. On 04/28/25 at 3:45 P.M., the [NAME] Unit Manager (UM) [LPN #406] called Resident #160's daughter and informed her of Resident #49 being in Resident #160's room and Resident #160 having her pants around her knees. On 04/28/25 at 5:30 P.M., the DON and the Administrator called Resident #160's daughter to ask if she could look at the video in the room. The daughter stated she had already looked at it and there was nothing on it. On 08/08/25 at 1:24 P.M., Resident #160's daughter sent a text message to [NAME] UM LPN #406 informing her that she finally looked at the video and Resident #160 had been assaulted several times on 4/28/25 by another resident. On 08/08/25 at 1:26 P.M., [NAME] UM LPN #406 notified the Administrator and the DON of an allegation of resident-to-resident sexual abuse. On 08/08/25 at 1:30 P.M., the DON notified Division Director of Risk Management (DDRM) #725 and RDO #750 of an allegation of resident-to-resident sexual abuse. On 08/08/25 at 1:35 P.M., the Administrator submitted a Self-reported Incident (SRI) with the State Agency (SA). On 08/08/25 at 2:00 P.M., the family of Resident #49, who no longer resides at the facility, was made aware of the allegation of resident-to-resident sexual abuse. Resident #49 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transferred on 08/06/25 per family's request to be closer to family. On 08/08/25 at 2:15 P.M., [NAME] UM LPN #406 called the police to report the allegation of resident-to-resident sexual abuse. On 8/08/25 at 2:25 P.M., the DON called Resident #160's daughter and asked what was on the video. The daughter stated, my mom was being assaulted. The DON requested to see the video. The daughter stated that she couldn't come up today but would meet the DON on 8/09/25 at 1:00 P.M. The daughter refused to have Resident #160 sent to hospital for an examination. On 08/08/25 at 2:30 P.M., [NAME] UM LPN #406 notified Nurse Practitioner (NP) #800 of the allegation of resident-to-resident sexual abuse involving Resident #160. No new orders were given. On 08/08/25 at 2:37 P.M., DDRM #725 notified the current facility of Resident #49 of resident-to-resident sexual abuse allegation. On 08/08/25 at 2:45 P.M., [NAME] UM LPN #406 completed a skin assessment on Resident #160 with no concerns noted. On 08/08/25 at 4:00 P.M., the local Sheriff's Department arrived at the facility and took a report and informed the DON to please call them when Resident #160's daughter arrives on 08/09/25 as they would like to come to the facility and see the video. On 08/09/25 at 2:00 P.M., the DON called Resident #160's daughter to ask about her where abouts. Resident #160's daughter informed the DON that she would not be able to come to the facility today, but she would try to make it sometime next week. On 08/11/25 at 4:00 P.M., Resident #160 was placed on 1:1 supervision until the physician deems it is not needed and discontinues the order. On 08/13/25 from 5:00 P.M. to 8:00 P.M., the DON interviewed staff regarding knowledge of any residents that have a sexual relationship and or any inappropriate sexual behaviors. Any resident found to be having sexual relations with other residents would be reviewed by the physician and Interdisciplinary Team (IDT) to discuss the risks/benefits of sexual behavior and this would be discussed with the resident's guardian/representative and a plan of care would be developed. There were no other residents that were identified to be having a sexual relationship and there were no additional resident-to-resident sexual occurrences found. The DON reviewed all residents' charts with no findings. On 08/13/25 from 6:00 P.M. to 9:00 P.M., the DON educated 155 staff members on the facility's abuse and neglect policy which included: (a) What constitutes abuse and types of abuse and neglect; (b) Identification of signs and symptoms in residents and staff of potential abuse and abusers; (c) Actions to take when abuse is witnessed, suspected, or alleged; (d) Timely and appropriate reporting of witnessed, suspected, or alleged abuse to all responsible parties per facility policy; (e) Protection of resident while conducting a thorough investigation of alleged abuse; (f) Proper assessment of residents who have been or suspected to be abused; (g) Prevention of future incidents of abuse from occurring; (h) Sexual activity between residents including what constitutes sexual abuse per Centers for Medicare and Medicaid Services (CMS) guidelines and what to do when you identify inappropriate sexual behaviors including reporting to your supervisor, DON, or Administrator and holding a meeting with physicians, IDT and family to develop a plan of care for the resident. Staff were also educated on supervision of residents using the policy titled Unit Supervision with emphasis on rounding and checking on residents every two hours. Staff was educated in person, via OnShift software and via phone calls. On 08/13/25 from 6:00 P.M. to 8:00 P.M., the DON started additional skin checks on all residents and completed interviews with residents who have a BIMS of 13 or higher. On 08/13/25, Minimum Data Set (MDS) Nurse #426 updated Resident #160's care plan to reflect sexual behaviors. On 08/13/25 at 8:30 P.M., the Administrator held an ad hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the Immediate Jeopardy and abatement plan, the facility's abuse policy, and the resident-to-resident sexual abuse allegation and unit supervision. Staff present included the Administrator, the DON, the Assistant Director of Nursing (ADON), UM/LPN #502, UM/LPN #406, UM/RN #429, DDRM #725, Social Service Director (SSD) #447, RDO #750, Divisional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Director of Clinical Operations (DDCO) #752, and Medical Director (MD) #801 attended the meeting via phone. Beginning 08/14/25, SSD #447 will continue offering support to Resident #160 by weekly visits for four weeks then as needed. The DON will observe five residents weekly for four weeks, then three residents weekly for four weeks, then two residents weekly for four weeks to look for any inappropriate sexual behaviors between residents. The DON will complete observation rounds throughout the facility to verify that appropriate supervision is consistently being provided five times a week for four weeks, then three times a week for four weeks, then two times a week for four weeks. The Administrator will interview five staff members weekly for four weeks, then three staff members weekly for four weeks, then two staff members weekly for four weeks to determine if there have been any inappropriate sexual behaviors between residents. The Administrator or DON will monitor compliance with the above during monthly QAPI meetings for three months, then as needed for one year. Interviews on 08/18/25 from 8:55 A.M. through 12:00 P.M. with CNA #413, CNA #482, CNA #543, LPN #406, and Registered Nurse (RN) #448, and RN #562 revealed education was completed on abuse and supervision of residents on 08/13/25. Additional medical record review for Residents #18, #48, and #65 revealed no identified concerns. Although the Immediate Jeopardy was removed on 08/14/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four.? This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.? Review of the plan of care for Resident #160 revealed there was no care plan in place with interventions for sexual behaviors. Review of the progress note dated 04/28/25 at 4:25 P.M. revealed LPN #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area. Review of the progress note dated 05/01/25 at 9:58 A.M. revealed SSD #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage. Guardian was notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Social services will continue to follow up as needed. Review of the weekly skin check completed 04/28/25 at 2:28 P.M. revealed Resident #160 had no skin issues during sexual encounters. Review of the skin assessment dated [DATE] revealed Resident #160 had no skin issues noted. Review of the medical record for Resident #49 revealed an admission date of 03/21/23. Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven.? This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers. Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors. Review of the progress note dated 05/01/25 at 10:05 A.M. revealed SSD #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage. Guardian was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few notified. Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place. Observations from the electronic monitoring device dated 04/28/25 revealed the following: At 9:42 A.M. to 9:43 A.M., Resident #160 was in her wheelchair at the doorway when Resident #49 approached her. He kissed her lips and placed his hand inside her shirt to touch her breasts. Resident #49 walked in front of Resident #160 and attempted to touch her genital area. Resident #160 backed up in her wheelchair, and Resident #49 left the room. At 10:31 A.M. through 10:37 A.M., Resident #160 was seen sitting in her wheelchair by the window when Resident #49 startled her. Resident #49 rubbed Resident #160's right breast on the outside of her shirt and attempted to reach inside but she pulled away. Resident #49 attempted again to feel her breast and then kissed her. Both residents continue to engage in sexual activity. Resident #49 left the room. At 10:42 A.M., Resident #49 was seen re-entering the room where Resident #160 was lying on the bed with no pants and her depends down. Resident #49 began touching her genital area. Resident #49 pulled his penis out of his pants and placed her hand on it. At 10:43 A.M., Resident #49 was seen leaving the room. At 10:48 A.M., Resident #49 was seen walking by her room, and then comes into her doorway and sees Resident #160 lying in bed with no pants on and then turned around and leaves. At 10:56 A.M., Resident #160 was shown standing up on the side of the bed pulling up her depends and getting into her wheelchair. At 1:17 P.M. through 1:19 P.M., Resident #160 was in her room eating lunch when Resident #49 came into her room and attempted sexual advances towards Resident #160 and then left the room. At 1:29 P.M. through 1:30 P.M., Resident #49 entered Resident #160's room, kissed her and then reached down her shirt to touch her breasts. Resident #160 moved away. Resident #49 continued to try to kiss her and touch her, and then he left the room. At 2:35 P.M. through 2:37 P.M., Resident #160 entered the room in her wheelchair. Resident #49 entered a few seconds later and leaned down and kissed Resident #160 and started to place his hand in her shirt. Resident #160 appeared to be touching Resident #49's genital area. Resident #160 moved her wheelchair away, and Resident #49 left the room. At 3:21 P.M. through 3:28 P.M., Resident #160 was sitting on her bed when Resident #49 entered her room, gave her a piece of candy, and kissed her. He fondled her breast and then motioned her to feel his genital area. Both residents engaged in oral sex. Two staff members, LPN #491 and CNA #436 opened the door to Resident #160's room. Resident #49 quickly pulled up his pants and was motioned to leave the room by staff. Interview on 08/06/25 at 9:03 A.M. with CNA #471 revealed Resident #160 and Resident #49 continued to have inappropriate sexual behaviors after the incident on 04/28/25 including kissing each other. Interview on 08/06/25 at 9:07 A.M. with CNA #437 revealed Resident #160 and Resident #49 were witnessed kissing in the dining room and touching each other inappropriately in between each other's thighs. Interview on 08/06/25 at 10:41 A.M. with Resident #160 reported she did not have a male friend and did not recall being sexually active in the facility. Interview on 08/06/25 at 11:47 A.M. with Resident #49 revealed he had lots of lady friends but did not recall who Resident #160 was and denied being sexually active. Interview on 08/06/25 at 11:53 A.M. with the DON reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and CNA #436. The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed. The DON explained Resident #49 could not recall why he was in the room. The DON stated the facility completed an investigation but failed to give it to this surveyor. The DON also stated both residents had very low cognition. The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH). Interview on 08/06/25 at 2:48 P.M. with Resident #160's daughter revealed she never watched the video from 04/28/25. Resident #160's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete daughter stated UM #406 called her and told her Resident #160 and Resident #49 were found in her room with their pants off. Resident #160's daughter reported SSD #447 called her the following day and asked her to give consent to Resident #160 having sexual activity. Resident #160's daughter did not give consent. Interview on 08/06/25 at 3:31 P.M. with LPN #491 revealed CNA #436 was completing rounds when she called LPN #491 into Resident #160's room. LPN #491 stated Resident #160 was sitting on her bed with no pants or depends on, and Resident #49 was standing in front of her about two feet apart. Resident #49 was fully clothed and was asked to leave the room. LPN #491 explained she educated both residents and completed a head-to-toe assessment on Resident #160 with no negative findings. LPN #491 stated she tried to ensure Resident #160 and Resident #49 were separated the rest of the shift. Interview on 08/14/25 at 1:55 P.M. with UM/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on, sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete an SRI for the incident. UM/LPN #406 also stated an incident report was not completed. Interview on 08/14/25 at 3:22 P.M. with MD #801 verified Resident #160 had memory loss and some cognitive and behavioral issues. MD #801 reported Resident #49 had vascular dementia and post-traumatic stress disorder (PTSD). MD #801 stated Resident #49 had memory loss as well. MD #801 stated both residents had memory issues and could not state if she felt that either resident could give consent to sexual activity. Interview on 08/14/25 at 3:52 P.M. with CNA #436 reported on 04/28/25 she came onto shift at 3:00 P.M., and Resident #49 and Resident #160 were in the common area watching television. About 15-20 minutes later, CNA #436 walked by, and both residents were gone. CNA #436 stated she saw Resident #160's door was closed to her room, which wasn't unusual, but she had a gut feeling to go in and check. CNA #436 knocked on her door and went in and found Resident #160 on her bed with her pants halfway down her legs, and Resident #49 standing in front of her fully clothed. CNA #436 stated Resident #49 was asked to leave the room. CNA #436 explained Resident #160 became aggressive and started calling her names. CNA #436 reported neither resident was placed on a 1:1. Review of the facility policy titled, Unit Supervision, revealed the policy of the facility was to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff, and visitors. The Unit Supervisor was a licensed nurse with the skills and competency to safely and appropriately monitor and delegate tasks to others and perform duties consistent with safe and effective care and treatment of the assigned residents. Supervision responsibilities were assigned by the DON or designee to provide for the care and treatment of the residents, direct services of on-duty staff, and assume responsibility for a safe environment during the time the nurse was working the shift for the specific unit the nurse was assigned. This deficiency represents non-compliance investigated under Complaint Numbers 1259562 and 2585469. Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, staff interview, and policy review, the facility failed to monitor a resident's weight as ordered. This affected one (#01) resident out of four residents reviewed for nutritional status. The facility census was 164.Review of the medical record for Resident #01 revealed an admission date of 07/09/19 with medical diagnoses of left hemiplegia, chronic obstructive pulmonary disease, left above the knee amputation (AKA), hypertensive heart and chronic kidney disease. Review of the medical record revealed Resident #01 had discharged to the hospital on [DATE] and readmitted to the facility 07/08/25. Review of the medical record for Resident #01 revealed a quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, which indicated Resident #01 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, and bed mobility. Review of the MDS revealed Resident #01 did not transfer and did not indicate any weight loss. Review of the medical record for Resident #01 revealed a physician order dated 07/16/25 for weight to be obtained for four weeks upon admission and an order dated 08/03/25 for monthly weights. Review of the medical record for Resident #01 revealed no documentation to support the facility obtained weights 07/16/25, 07/23/25, 07/30/25, and 08/03/25. Review of the medical record revealed the last weight documented was on 06/20/25 at 158 pounds. Review of the medical record for Resident #01 revealed a weight entry note dated 08/03/25 at 12:14 P.M. which stated, unable to obtain weight. Interview on 08/07/25 at 9:26 A.M. with Dietician #710 stated Resident #01 was at risk for weight loss due to multiple medical conditions and pressure ulcers. Dietician #710 stated Resident #01's weights were not obtained in July or August 2023 due to the Hoyer (mechanical) lift weight broken and staff did not have a way to weight Resident #01. Review of the facility policy titled, Resident Height and Weight, stated staff are to obtain weekly weight times four weeks for baseline and for stable residents will be weighted monthly thereafter, unless physician or diagnosis indicates otherwise Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and policy review, the facility failed to ensure enteral feeding supplies were replaced according to professional standards. This affected one (Resident #11) of two residents sampled for enteral feedings. The census was 164.Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, unspecified major depressive disorder, unspecified moderate dementia with psychotic disturbance, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severely impaired dementia, had self-directed behaviors, did not wander, and did not reject care. Review of the care plan dated 02/24/23 revealed Resident #11 had g-tube status. Interventions included administer medications via g-tube per orders, administer flushes as per protocol, enhanced barrier precautions, check for placement and residuals, and provide tube feeding as ordered. Review of the medical record revealed Resident #11 had physician orders dated 07/27/25 for Jevity 1.5 at 70 milliliters (ml) per hour for eight hours nocturnally from 9:00 P.M. to 5:00 A.M. for a total of 560 ml's per eight hours daily. Observation on 08/07/25 at 2:10 P.M. revealed a Kangaroo pump bag was hanging at bedside and contained a brown liquid that was labeled Jevity 1.5 and was dated 08/05/25. Interview on 08/07/25 at 2:34 P.M. Licensed Practical Nurse (LPN) #434 verified the tube feeding bag hanging at Resident #11's bedside was dated 08/05/25. LPN #434 stated unused tube feeding solution should be discarded 24-hours after opening. Review of policy titled, Enteral General Nutritional (tube feeding) Guidelines, not dated, revealed staff changed syringes, tubing, and bottles used for tube feeding daily and labeled and dated items. Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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, Nurse Practitioner (NP) interview, and policy review, the facility failed to administer medication as ordered which resulted in a significant medication error. This affected one (#02) resident out four residents reviewed for medication administration. The facility census was 164. Review of the medical record for Resident #02 revealed an admission date of 02/09/23 with medical diagnoses of right hemiplegia, chronic obstructive pulmonary disease, end stage renal disease, dependence on dialysis, and bipolar disorder. Review of the medical record for Resident #02 revealed a Minimum Data Set (MDS) assessment, dated 07/07/25, which indicated Resident #02 was cognitively intact and was dependent upon staff for toilet hygiene, showers/bathes, transfers and bed mobility. Review of the medical record for Resident #02 revealed a physician order dated 11/30/24 for Midodrine (hypotension medication) oral tablet 2.5 milligram (mg) one tablet by mouth every eight hours as needed for hypotension. Hold if systolic blood pressure (SBP) is greater than 110 and administer if SBP is less than 110. Review of the medical record for Resident #02 revealed a blood pressure reading on 06/03/25 of 97 (SBP)/50 diastolic blood pressure (DPB) milliliters in mercury (mmHg). Review of the medical record revealed pre-dialysis assessments on 07/24/25 with a documented blood pressure of 105/78 mmHg, on 07/31/25 with documented blood pressure of 106/64 mmHg, and on 08/05/25 with a documented blood pressure of 104/67 mmHg. Review of the medical record for Resident #02 revealed the Medication Administration Records (MAR) for June, July and August 2025 did not have documentation to support Midodrine was administered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25. Interview on 08/07/25 at 10:23 A.M. with NP #800 stated the order was supposed to be entered to administer Midodrine 2.5 mg one tablet every eight hours for hypotension and to hold if SBP is greater than 110 and to administer if SBP less than 110. NP #800 stated Resident #02 should have her blood pressure checked three times per day for the facility to monitor her for possible Midodrine administration. NP #800 also stated the facility staff should have administered Midodrine as ordered prior to dialysis. NP #800 confirmed the facility had not administered Midodrine as ordered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25. Review of the facility policy titled, Medication Administration, revealed the facility is to provide resident centered care the meets the psychosocial, physician, and emotional needs and concerns of the residents. The policy continued to state staff are to administer medication only as prescribed by the provider. This deficiency represents non-compliance investigated under Complaint Number 1259566. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2025 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of documentation from an employment agency, review of documentation from Board of Executives of Long-Term Services and Supports (BELTSS), interview with Board Administrator at BELTSS, and staff interview, the facility failed to ensure Administrator had a valid Nursing Home Administrator (NHA) license. This had the potential to affect all the residents. The facility census was 164. Interview on 08/05/25 at 10:09 A.M. with Regional Director of Operations (RDO) #750 confirmed the facility had employed interim NHA #630 from 05/12/25 through 06/10/25. RDO #750 stated interim NHA #630 had been hired through an employment agency and provided documentation interim #630 had an active NHA license. Interview on 08/06/25 at 4:15 P.M. with Board Administrator #635 stated BELTSS was notified of a concern about the validity of interim NHA #630's license. Board Administrator #635 stated after an investigation it was determined that interim NHA #630 had used the license number for NHA ##700 to obtain a position as a NHA. Board Administrator #635 stated interim NHA #630 and NHA #700 had similar names but different Social Security Numbers, addresses, and date of birth s. Board Administrator #635 confirmed interim NHA #630 did not have a valid NHA license. Review of the documentation from the employment agency provided to the facility revealed interim NHA #630's date of birth was 10/23/73 and resided in Cincinnati. Review of the documentation revealed interim NHA #630 had used NHA license number 7258. Review of documentation from BELTSS revealed NHA #700 had an active license of number 7258, a date of birth of [DATE] and resided in Englewood. Review of BELTSS documentation revealed interim NHA #630 was registered as an Administrator in Training and did not have an active NHA license. This deficiency represents non-compliance investigated under Complaint Number 2578224. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365877 If continuation sheet Page 21 of 21