Inspection·June 20, 2019

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to initiate a baseline and/or comprehensive care plan related to a seizure risk. This affected one (Resident #72) of five residents reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 88. Findings include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Herpes Viral Encephalitis (virus causing swelling in the brain) and dementia without behaviors. Review of the resident's physician orders revealed the resident was prescribed medications including Vimpat 150 milligrams (mg.) twice daily for seizures, Phenytoin Sodium Extended Capsule 100 mg. twice daily for seizures, and Keppra Tablet 1000 mg. twice daily for seizures. Review of the resident's care plans revealed they were silent that any care plans were initiated related to the resident's risk for seizure activity. Interview on 06/20/19 at 7:20 A.M. with the Director of Nursing (DON) verified the medical record was silent for a care plan related to the resident's risk for seizures. The DON stated he would review with the appropriate staff and ensure a care plan was put into place. Review of the facility policy Interdisciplinary Care Planning, dated 11/2016, revealed the resident care plans are a communication tool that guide members of the facility interdisciplinary team on how to meet each individual residents needs. Care plans should include managing a residents risk factors and planning for care to meet their needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 2 of 5 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 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Post Acute 1001 Alex Bell Road Centerville, 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, staff interview, and review of facility policy, the facility failed to provide proper positioning for a resident requiring total assistance. The affected one (Resident #25) of two residents reviewed for positioning, during the annual survey. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, major depressive disorder, unspecified psychosis, insomnia and polyosteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/19, revealed Resident #25 was severely cognitively impaired with no noted behaviors. The resident required extensive two-person assistance with mobility and transfers. Observations conducted on 06/17/19 at 11:35 A.M., 06/18/19 at 9:44 A.M., 06/18/19 at 5:43 P.M., 06/19/19 at 12:39 P.M. and 06/20/19 at 8:18 A.M. revealed Resident #25 was observed in a custom broda chair (special wheelchair). During every observation, Resident #25 was observed with no leg rest noted on chair, and legs were observed dangling from chair and unable to rest on the ground. Interview conducted on 06/19/19 at 2:08 P.M. with State Tested Nursing Assistant (STNA) #60 stated Resident #25 was unable to self propel in the wheelchair, and it has no foot rest. STNA #60 stated it really defeats the purpose of the broda chair since the resident was always sitting with her legs out and unable to touch the floor. Interview conducted on 06/19/19 at 2:40 P.M. with Licensed Practical Nurse (LPN) #43 stated Resident #25 was in the broda chair and was not able to put feet flat on the ground or push herself. LPN #43 verified there was no leg rest on the wheelchair for the resident to be able to rest her legs. LPN #43 stated he was unsure of how long the resident had been in the chair, but it had been a long time. Interview conducted on 06/20/19 at 9:21 A.M. with the Administrator, Nursing Supervisor (NS) #57, and Therapy Manager (TM) #98. NS #57 stated Resident #25 was last able to move herself in the wheelchair about a year ago, and she was unsure why there was never foot rest put on the wheelchair. The Administrator stated hospice was in the facility every day, and she was not sure why no one ever assessed or noticed her legs dangling in the chair. TM #98 stated residents were only assessed for positioning when a request was put in, and to her knowledge no request was ever sent in regarding Resident #25's positioning in the broda chair. Review of the facility policy Transfer:bed-Chair/Wheelchair, dated 01/2011, revealed when residents are assisted to the wheelchair, the resident should be aligned with proper positioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 3 of 5 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 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Post Acute 1001 Alex Bell Road Centerville, 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interviews, and review of facility policy, the facility failed to obtain and provide medication timely. This affected one (Resident #72) of five residents reviewed for unnecessary medication during the annual survey. The facility census was 88. Findings including: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Herpes Viral Encephalitis (virus causing swelling in the brain), difficulty waking, urinary tract infection, hypertension, and dementia without behaviors. Review of the admission Minimum Data Set (MDS) assessment, dated 06/06/19, revealed Resident #72 was severely cognitively impaired with disorganized thinking behavior continuously present. Review of the physician orders revealed the resident was prescribed medications on admission including Vimpat 150 milligrams (mg.) twice daily for seizures, Phenytoin Sodium Extended Capsule 100 mg. twice daily for seizures, and Keppra Tablet 1000 mg. twice daily for seizures, Quetiapine 25 mg. twice a day for behaviors, Aspirin 81 mg. daily, Magnesium Oxide 400 mg. daily, Oyster Shell Calcium + D3 1000-800 mg. daily, Pantoprazole Sodium 40 mg. daily for reflux, and Donepezil HCL five mg. twice daily for dementia. Daily medication were scheduled at 9:00 A.M. and twice daily medication were scheduled at 9:00 A.M. and 9:00 P.M. Interview conducted on 06/18/19 at 5:45 P.M. with Resident #72's daughter stated when the resident was admitted to the facility there was some confusion with his medication. The resident was admitted to the facility on [DATE] between 3:00 A.M. and 4:00 A.M. The resident did not receive any of his medication at 9:00 A.M. and was without his seizure medication for at least the first day. Interview conducted on 06/19/19 at 2:23 P.M. with Licensed Practical Nurse (LPN) #43 stated if residents were admitted to the facility with seizure medication, you would pull the medication out of the pixel machine, which has majority of medications. If the medication was not in the pixel machine, the nurse should have it drop shipped from the pharmacy as soon as possible. Interview conducted on 06/20/19 at 7:20 A.M. with the Director of Nursing (DON) revealed Resident #72's medication were reviewed and verified the resident did not receive any of his 9:00 A.M. medication on 05/30/19 and also missed his 9:00 P.M. dose of his Keppra and Vimpat, on 05/31/19 missed both doses of the Vimpat. The DON stated he was not aware the resident went that long without the seizure medication. He would expect staff to pull the medication from the pixel and also get the order if there was not one for ordered medications. The DON verified the medication was available in the pixel machine, and stated if it wasn't in the pixel, the pharmacy could have provided to the facility within four hours, if the staff requested them to drop it. Review of the facility policy Requirement and Guidelines for Clinical Record Content, dated 2017, revealed when residents are admitted , the facility receives physician orders for the immediate care of the resident that include at a minimum orders for diet, medication and routine care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 4 of 5 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 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Centerville Post Acute 1001 Alex Bell Road Centerville, 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on record review and staff interview, the facility failed to timely act upon recommendations made by the facility pharmacist. This affected one (Resident #54) of five residents reviewed for unnecessary medication during the annual survey. The facility census was 88. Findings include: Review of the medical record revealed Resident #54 was admitted to the facility 06/16/13 with diagnoses including unspecified dementia with behavioral disturbance, Alzheimer's disease and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 05/29/19, revealed Resident #54 was severely cognitively impaired with no noted behaviors. The resident received antipsychotic and antianxiety seven of the seven days during the look back period. Review of the Medication Regimen Review (MRR), dated 02/14/19, revealed the facility pharmacist recommended Resident #54's medication Risperdal (antipsychotic) 0.25 milligram (mg.) tablet to be gradually reduced from twice a day to daily. Further review of the MRR revealed the physician did not review the recommendation until 06/06/19. Review of the MRR, dated 03/21/19, revealed the facility pharmacist recommended for Resident #54's medication Melatonin three mg. (for insomnia) to be discontinued to ensure the medication was still needed. Further review of the MRR revealed the physician did not review the recommendation until 05/15/19, and the physician accepted for the medication to be discontinued. Review of the resident's physician orders revealed that although the physician accepted for the Melatonin to be discontinued on 05/15/19, the order was not transcribed into the system and/or discontinued until 05/24/19, and the resident continued to receive the medication an additional nine days. Interview conducted on 06/20/19 at 12:01 P.M. with the Director of Nursing (DON) stated some MRR's were addressed by the facility physician and some were reviewed by the psychiatrist. The DON stated he can not explain what caused the gap in delay from the recommendation being made, and the recommendation being addressed by the appropriate physician. Interview conducted on 06/20/19 at 3:46 P.M. with the facility Physician (DR) #299 verified the MRR's for Resident #54 were not reviewed timely and verified he would expect them to be addressed well before a couple months. DR #299 stated he didn't know what happened, and where the recommendations got lost along the way. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 5 of 5