Inspection·October 10, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 09/14/24 at 5:13 P.M., which stated Resident #115 had been sent out for a psychiatric evaluation for risk of harm to self and others per the Administrator's request. Review of the facility SRI, dated 09/14/23, revealed an investigation was completed for allegation of sexual abuse against Resident #102 by Resident #115. Resident #102 alleged that Resident #115 touched her inappropriately. The investigation included staff and resident interviews, staff education on abuse, resident physical assessments, and notification to Resident #102's guardian, the police, and physician. Interview on 10/10/24 at 9:54 A.M. with Resident #102's guardian stated he was notified on 09/14/24 by the Administrator that Resident #102 had been inappropriately touched by Resident #115. Resident #102's guardian stated he was informed that Resident #115 had been touching Resident #102 with his fingers, maybe even penetrating Resident #102 and was kissing her. Resident #102's guardian stated Resident #102 informed him that Resident #115 touched her, and she did not like it. Resident #102's guardian stated the police were notified and the incident was being investigated but he was informed by the police that charges would probably not be filed due to lack of evidence. Resident #102's guardian stated he did not believe Resident #102 would be able to understand the meaning of consent or even sexual intercourse. Resident #102's guardian stated Resident #102 was not sent out to the hospital for a physical examine per his request because he did not want to put Resident #102 through the experience since there was not any evidence of sexual intercourse. Interview on 10/10/24 at 10:16 A.M. with Administrator stated she was informed by the facility staff on the morning of 09/14/24 that Resident #102 had reported to staff that Resident #115 kissed her and that they were in a relationship which included sexually inappropriate touching and kissing. Administrator stated she immediately started an investigation and notified the police department. Administrator stated she interviewed Resident #115 who admitted to kissing Resident #102, putting his penis on her mouth and touching her inappropriately. Administrator stated she interviewed Resident #102 who stated Resident #115 put his penis in her mouth and touched her private area. Administrator stated Resident #102 denied having sexual intercourse with Resident #115. Administrator stated Resident #102 and Resident #115's stories had inconsistencies regarding the number of times they were together or what actually occurred between them. Administrator stated no staff reported ever seeing Resident #102 or Resident #115 together in a private area but only in therapy gym. Administrator stated a few days prior to the incident on 09/14/24, the staff were made aware that Resident #102 had a crush on Resident #115 who she met in therapy. Administrator stated Social Work staff notified Resident #102's guardian of Resident #102's infatuation with Resident #115 and he asked that the two residents' only see each other in public common areas. Administrator stated Resident #115 had no history of sexual abuse but would make lewd comments to staff. Administrator stated staff never observed Resident #115 in Resident #102's room. Administrator stated Resident #115 was put on one-on-one supervision on 09/14/24 until he discharged on 10/09/24 and had no further contact with Resident #102. Interview on 10/10/24 at 11:16 A.M. with Social Service designee (SS) #208 and Social Service Director (SSD) #209 revealed SS #208 stated Resident #102's guardian was notified that Resident #102 and Resident #115 were in a relationship on 09/12/24 and that Resident #102's guardian did not approve of the relationship but stated they could be together in public viewing areas. SSD #209 stated the facility was not aware of any inappropriate contact between the two residents at that time but wanted to make Resident #102's guardian aware of the relationship. SS #208 stated the facility intervention to ensuring Resident #102 and Resident #115 were not together in a private area was to increase staff rounds on Resident #102's hall since she required staff assistance for transfers and wheelchair mobility. SS #208 stated Resident #102 has not had any behaviors, crying, or withdrawal because of (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 10/10/2024 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 0600 the interaction between her and Resident #115. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Abuse, reviewed 11/20/23, stated all residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The policy stated abuse included verbal, sexual, physical, and mental abuse. Residents Affected - Few The deficient practice was corrected on 09/15/24, when the facility implemented the following corrective actions: • On 09/14/24, Resident #115 was put on one-on-one supervisor. • On 09/14/24, Administrator initiated SRI and investigation which included interviews with residents and staff. • On 09/14/24, Administrator notified the local police department, Resident #102' guardian, and Medical Director. • On 09/14/24, Regional Clinical Service Manager provided education to Administrator and Director of Nursing (DON) regarding abuse. • On 09/14/24, facility nurse completed head to toe assessment for Resident #102 and had no negative findings. • On 09/14/24, DON/Social Service completed interviews with all residents and no concerns were voiced about abuse except for Resident #102. • On 09/14/24, Administrator, DON, and unit managers educated all staff on abuse. Education was completed by 09/15/24. • On 09/14/24, Resident #115 was sent to the hospital for a psychiatric evaluation and returned to the facility 09/15/24. • (continued on next page) 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 10/10/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/14/24, Quality Improvement Performance Assurance (QAPI) meeting conducted with Medical Director, DON, and Administrator. • On 09/14/24, Unit Managers to audit three residents weekly for four weeks. No additional abuse concerns were identified. • On 09/14/24, DON to interview three staff members weekly for four weeks on the facility abuse policy. No additional abuse concerns were identified. • On 09/15/24, DON and floor staff completed head to toe assessments on all residents. No additional abuse concerns were identified. This deficiency represents non-compliance investigated under Complaint Number OH00158222. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366100 If continuation sheet Page 4 of 4