Inspection·December 13, 2023

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 record review, observations and staff and resident interviews, the facility failed to accurately assess, monitor and/or document resident with bruising. This affected two ( #10 and #11) of three residents reviewed for skin breakdown. The facility census was 96. Residents Affected - Few Findings include: 1. Review of medical record for Resident #10 revealed admission date of 05/25/23. Diagnoses included heart attack, stage four kidney disease, congestive heart failure, peptic ulcer and anxiety. The resident remains at the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed he required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Resident #10's Brief Interview Mental Status (BIMS) was not assessed. Observation and interview on 12/12/23 at 1:20 P.M. of Resident #10 revealed multiple, scattered bruising on both of the resident's arms. Resident #10 stated the bruises were due to his blood thinners and old, thin skin. Review of Resident #10's progress note dated 12/06/23 revealed both arms were assessed to have healing bruises which were attributed to compression sleeves. Resident #10 was documented to have no concerns. Review of 12/03/23 and 12/10/23 skin assessment revealed no documentation or assessment of bruising. 2. Review of medical record for Resident #11 revealed admission date of 10/16/23. Diagnoses included hemiplegia non-dominant following stroke, asthma, malignant breast cancer with bone metastasis and dementia. The resident remains at the facility. Review of Resident #11's admission Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 12 indicating impaired cognition. She required supervision for bed mobility, moderate assistance for transfers, and eating. Review of Resident #11's progress notes and skin assessments from 11/28/23 to 12/07/23 revealed no documentation of bruising. Observation on 12/11/23 at 10:24 A.M. of Resident #11 revealed a healing circular bruise to the upper, proximal aspect of her right arm. Further observations revealed three small, healing bruises were noted to Resident #11's left forearm. Interview on 12/12/23 at 2:52 P.M. with Unit Manager (UM) #32 verified he observed bruising of both arms of Resident #10, and there was no documentation or assessment of bruising on the 12/03/23 or 12/10/23 skin assessment. UM #32 acknowledged there was no accurate description or measurement of the bruises for Resident #10. UM #32 also verified he observed bruising of Resident #11, and there was no documentation or assessment of bruising on the 11/28/23 to 12/07/23 skin assessment. UM #32 acknowledged there was no accurate description or measurement of the bruises for Resident #11. UM #32 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 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 Level of Harm - Minimal harm or potential for actual harm shared the facility had a policy for skin care management but did not have a policy for skin assessments or wound management. This deficiency is based on incidental findings discovered during the course of this complaint investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366100 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 record review, observations, staff interviews and review of facility policy, the facility failed to ensure fall interventions were implemented per the residents care plan. This affected two (#10 and #12) of three residents reviewed for falls. The facility census was 96. Findings include: 1. Review of medical record for Resident #10 revealed admission date of 05/25/23. Diagnoses included heart attack, stage four kidney disease, congestive heart failure, peptic ulcer and anxiety. The resident remains at the facility. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed he required extensive two person assistance for bed mobility, transfers, toileting and supervision for eating. Resident #10's Brief Interview Mental Status (BIMS) was not assessed. Review of Resident #10's care plan revealed the resident was at risk for falls. There was an intervention initiated 08/23/23 for a low bed. Review of Resident #10's progress notes dated 08/28/23 revealed the resident was found on the floor, laying on his right side after sliding from the bed. Review of Resident #10's fall investigation dated 08/28/23 fall revealed an intervention for low bed was initiated. Observation on 12/11/23 at 11:50 A.M. revealed Resident #10's bed was not in the lowest position. This was verified at 11:54 A.M. by State Tested Nursing Assistant (STNA) #35. 2. Review of medical record for Resident #12 revealed admission date of 08/08/23. Diagnoses included hemiplegia following stroke, heart failure, depression, and anemia. The resident was remains in the facility. Review of Resident #12's quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating impaired cognition. He required set up for eating, maximum assistance for toileting, bed mobility and no documentation of transfers. Review of Resident #12's care plan revealed the resident was a fall risk due to history of falls with an intervention initiated on 09/25/23 to have the bed in lowest position while in bed. Observation on 12/11/23 at 8:42 A.M. revealed Resident #12 appeared to be sleeping and laying on his back. Further observations of Resident #12 revealed the bed was not in the lowest position. This was verified with Registered Nurse (RN) #27 at 8:45 A.M. Review of the facility fall policy last reviewed 06/08/22 documented Staff would identify pertinent interventions to try and prevent subsequent falls. This deficiency represents non-compliance investigated under Complaint Number OH000148920. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 4 of 4