Inspection·June 16, 2022

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 06/14/2022 at 7:35 A.M., State Tested Nurse Assistant (STNA) #10 verified Resident #71's call light was laying across the nightstand out of the resident's reach. 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, unspecified depression, left hand contracture, functional quadriplegia, tracheostomy, unspecified heart failure, type II diabetes, category blindness to left eye, and unspecified convulsions. Review of the most recent annual MDS assessment dated [DATE] revealed Resident #47 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Observation on 06/14/22 at 12:30 P.M. revealed Resident #47's call light was not within reach or near him. Resident #47's call light was on the floor and partly under the bedside table. During an interview on 06/14/22 at 12:30 P.M., Registered Nurse (RN) #40 verified Resident#47's call light was on the floor. Review of facility policy titled Call Light Policy, updated 10/2020 revealed to always position call light correctly for use and within reach. A clip may be used to secure the light. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 2 of 7 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 06/16/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure physician orders for oxygen therapy were implemented. This affected one resident (#30) of three residents reviewed for oxygen. In addition, the facility failed to obtain physician orders for oxygen use. This affected one resident (#73) of three residents reviewed for oxygen. The facility census was 88. Residents Affected - Few Findings Included: 1. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnosis included pulmonary hypertension, Covid-19 on 06/07/22, major depressive disorder, dementia, mild cognitively impaired, and cardiomyopathy. Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed the Brief Interview of Mental Status was not completed. Resident #30 was alert and not able to answer questions in the interview. The resident required extensive two-person physical assistance for bed mobility, and transfers. The resident required total dependence of one-person physical assistance for dressing, and bathing. Resident #30 required extensive one-person physical assistance for personal hygiene, and toilet use. Review of the plan of care dated 05/03/22 revealed Resident #30 was at risk for congestive heart failure for fluid volume overload. Interventions included check breath sounds and monitor for labored breathing, monitor lab work, give oxygen therapy as ordered, vitals as needed, and weight monitoring. Review of the physician order dated 08/06/2021 revealed Resident #30 had an order for oxygen at two liters per minute (L/m) via a nasal cannula to keep the oxygen saturation level above 92 percent every day and night shift for hypoxia. Observation and interview on 06/15/22 at 4:50 P.M. with Licensed Practical Nurse (LPN) #114 verified Resident #30's oxygen concentrator was set on 1.5 L/m. LPN #114 said she was not sure how many liters the physician ordered for oxygen use. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, heart failure, cerebral palsy, and hypertension. Review of the MDS quarterly assessment dated on 05/11/22 revealed Resident #73 had a Brief Interview of Mental Status (BIMS) score of an 11 indicating she was mildly cognitively impaired. Resident #73 required extensive two-person assistance for bed mobility, toilet use, and dressing. Resident #73 required total dependence two-person physical assist for all transfers. Review of the plan of care dated 06/15/22 revealed Resident #73 was at risk for altered cardiovascular status related to congestive heart failure and atrial fibrillation. Interventions included assess for shortness of breath, encourage low fat and low salt intake, monitor and report to physician changes in lung sounds on auscultation, and monitor and report to physician chest pain or pressure. Resident was also at risk for altered respiratory status and difficulty in breathing related to recovering from Covid and congestive heart failure. Interventions included administer medications and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 3 of 7 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 06/16/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inhalers as ordered, provide oxygen at four liters via nasal cannula to maintain oxygen saturation above 90 percent. Review of the physician orders revealed Resident #73 had no order for oxygen use. Observation on 06/13/22 at 3:05 P.M. revealed Resident #73 was on 3.5 liters of oxygen via nasal cannula delivered by an oxygen concentrator. During an interview on 06/13/22 at 3:13 P.M., the Director of Nursing (DON) verified Resident #73 had no physician order for oxygen use. During an observation and interview on 03/13/22 at 3:20 P.M. the DON verified Resident #73 was receiving 3.5 liters of oxygen via nasal cannula delivered by a concentrator in the resident's room. Review of policy titled Oxygen Administration last updated 07/2017 revealed oxygen was administered by a licensed nurse according to physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 4 of 7 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 06/16/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and policy review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) appropriately. This had the potential to affect all 88 residents who reside in the facility. The facility census was 88. Residents Affected - Many Findings Included: 1. Observation on 06/13/22 at 12:24 P.M. with Registered Nurse (RN) #31 who worked on the skilled hall, came out of Resident #326 room wearing a yellow procedure gown, and gloves. RN #31 had an N95 mask and a face shield on. RN #31 walked from room [ROOM NUMBER] to room [ROOM NUMBER] to retrieve a straw for Resident #326. RN #31 walked back to Resident #326's room after retrieving a straw from medication cart located in the hall. At no time was RN #31 observed removing her yellow protective gown or gloves. There was no observed hand hygiene completed after leaving he residents room or returning to the room of Resident #326. Interview on 06/13/22 at 12:27 P.M., RN #31 verified she came out of Resident #326's room with a yellow procedure gown and gloves on. RN #31 said she had not touched anything in Resident #326's room; and was why she had not doffed her Personal Protective Equipment (PPE). Interview on 06/13/22 at 12:35 P.M., with Infection Preventionist Registered Nurse #58 said the staff would need to doff their PPE before leaving a room, if a resident requested an item to take back into their room. The Infection Preventionist Registered Nurse #58 stated the staff should have doffed the PPE, completed hand hygiene, then retrieved the item the resident requested. The staff should not walk in the hall with potentially contaminated PPE, after being in a quarantined or Covid positive resident's room. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed that the donning and doffing of gowns are removed at the exit of the patient care area; gown to be deposed of or placed in a leak-proof laundry bag at the exit area for re-processing and washing (reusable). 2. Observation on 06/13/22 at 12:45 P.M. with Maintenance Director #109 who was wearing his surgical mask hanging from one ear, and his mouth and nose was exposed on the Medbridge unit, in a resident care area standing near room [ROOM NUMBER]. Observation on 06/13/22 at 12:50 P.M. the Health and Safety Consultant Surveyor toured the facility with Maintenance Director #109 who had not worn his mask. The Maintenance Director was observed not wearing his mask correctly or not wearing it at all while in a resident hallway number two. Maintenance Director #109 was not wearing his mask while testing the fire alarm at 3:14 P.M. while he was at the nurse's station on the 2nd floor. Observation on 06/13/22 at 3:40 P.M. Maintenance Director #109 walked down to the Heritage nursing station with his mask hanging from his left ear and not covering his nose and mouth. Interview on 06/16/22 at 4:28 P.M., the Maintenance Director #109 said he had not worn his surgical mask correctly when it was hanging on his ear while in the patient care area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 5 of 7 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 06/16/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed face masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. As of 03/26/20, all Senior Care service lines (SNF, AL, Home Health, Hospice, Palliative Care) are under universal masking criteria. Community-based staff entering a Senior Care center are also required to follow universal masking criteria as well as escalate Personal Protective Equipment use based on the following employee guidance. Donning and doffing at skilled nursing facility and assisted living: the masks are donned at the beginning of shift and only removed during scheduled breaks out of the patient care areas. Masks are removed outside of the patient care area. They are discarded when visibly soiled and in no case should they be worn beyond the end of the individual's shift. 3. Observation on 06/14/22 at 9:14 A.M. RN #56 took her black cloth mask off at the resident's room and placed a N95 mask on her face to enter a Covid quarantine room. Interview on 06/14/22 at 9:15 A.M., RN #56 said she was wearing a cloth mask, but not into Covid positive or Covid quarantine resident's room. RN #56 said she would take off the black cloth mask, change into a N95 and the rest of the PPE at each resident's door. RN #56 said she just left her cloth black mask on her nurse's cart next to the resident's room door. Observation on 06/14/22 at 9:36 A.M. Resident #332 activated the call light and asked for anxiety medication. RN #56 answered the call light at 9:38 A.M. wearing a black cloth face mask. RN #56 deactivated the call light and exited the room. At 9:40 A.M. RN #56 returned to the room wearing a black cloth mask and administered medication to Resident #332 and spoke to the resident less than two feet away. Interview on 06/15/22 at 2:38 P.M., the Administrator said employees were to wear a surgical mask or higher, and not a cloth mask. Interview on 06/15/22 at 3:50 P.M., Resident #332 said RN #56 wore a cloth mask her entire shift while working at the facility. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed in no where stated in the guide that a cloth mask was allowed to be worn as an employee. Masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. 4. Observation on 06/15/22 at 3:50 P.M. with State Tested Nursing Assistant (STNA) #120 standing near the nurse's station talking to Certified Nurse Aide (CNA) #33 who was sitting at the nurse's station charting on the computer. STNA #120 and CNA #33 wore face shields on but their surgical masks were at their chin resting, with their mouth and nose exposed to the air. Resident #57 was sitting less than four feet in a chair next to the next to the nurses' station with another unknown resident sitting on the other side. Resident #57 was not wearing a face mask nor the other unknown resident. Both STNA #120 and CNA #33 were observed not wearing their surgical mask correctly for over five minutes. Interview on 06/15/22 at 4:25 P.M., the STNA #120 said her and the other aide CNA #33 were wearing their surgical mask at their chin. STNA #120 said she knew two residents were sitting next to the nurse's station. STNA #120 verified there was two residents in the area, and said she was hot and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 6 of 7 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 06/16/2022 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 0880 needed air. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed face masks that are specified in the usage guide lists procedure mask, N-95 respirator, face shield, goggles, safety glasses with protectant to guard eyes, gown (disposable or cloth), and surgical gloves. As of 03/26/20, all Senior Care service lines (SNF, AL, Home Health, Hospice, Palliative Care) are under universal masking criteria. Community-based staff entering a Senior Care center are also required to follow universal masking criteria as well as escalate Personal Protective Equipment use based on the following employee guidance. Donning and doffing at skilled nursing facility and assisted living: the masks are donned at the beginning of shift and only removed during scheduled breaks out of the patient care areas. Masks are removed outside of the patient care area. They are discarded when visibly soiled and in no case should they be worn beyond the end of the individual's shift. Residents Affected - Many 5. Observation on 06/15/22 at 4:55 P.M. CNA #90 came out of room [ROOM NUMBER], where a newly admitted resident resided, with only a face shield and a surgical mask on. On the resident's door was signs posted for Covid-19 Quarantine. Interview on 06/15/22 at 4:59 P.M., the CNA #90 said she came out of the room [ROOM NUMBER] who was quarantined for Covid-19. CNA #90 said she was not aware she had to wear an N95 mask into a quarantine room, because she was fully vaccinated. CNA #90 was not aware their was two Covid positive cases on the unit. Interview on 06/15/22 at 5:00 P.M., the Licensed Practical Nurse (LPN) #114 verified CNA #90 only had a surgical mask on, when exiting the room. LPN #115 said the aide should have worn an N95 mask because she was in a Covid-19 quarantine room. Review of the facility policy titled Personal Protective Equipment Usage Guide, dated 06/09/2022 revealed when to use N-95 respirators are to be used when providing care or services within six feet of patient with suspected or confirmed Covid-19, during aerosol-generating procedures, or during nasopharyngeal specimen collection. When donning and doffing of N-95 mask, the respirators are to be seal tested every time the respirator was donned. They are discarded when visibly soiled and changed in between patients. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 7 of 7