Inspection·May 21, 2025

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. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure a clean and homelike dining experience. This had the potential to affect the 11 facility-identified residents (#02, #03, #07, #18, #19, #24, #39, #48, #50, #59, #61) who ate their meals in the main dining room. The facility also failed to ensure resident rooms were clean and sanitary. This affected three (Residents #53, #62, #123) of 19 residents sampled. The facility census was 68 residents. Findings include: 1. Observation on 05/18/25 at 8:36 A.M. of breakfast revealed residents were served the meal in Styrofoam containers. Interview on 05/18/25 with Dietary Staff (DS) #392 confirmed residents were being served their meal in Styrofoam containers because another dietary staff member had called off and they were trying to minimize the amount of dishes that needed to be washed. 2. Observation on 05/19/25 at 12:24 P.M. revealed there was a large vent in the ceiling in the middle of the dining room which was caked in a thick dark gray and fuzzy material which was visibly blowing in the air coming from the vent. Further observation revealed the curtains on the double doors from the dining room to the facility smoking area contained a gray and fuzzy coating. The curtain rod above the window in front of the tray line condiment station was caked in a dark gray and fuzzy material and a house fly was stuck to the curtains. Thee sprinkler heads in the dining room were also caked with a gray fuzzy material. There was a string of the gray fuzzy material approximately 12 inches in length dangling from a ceiling tile above a table in the dining area. Interview on 05/19/25 at 12:46 P.M. with Dietary Manager (DM) #389 confirmed the gray fuzzy material throughout the dining area on the vent, ceiling, curtains, and sprinkler heads, and confirmed the fly on the curtains was dead and stuck to the curtains. Review of the facility policy titled Safe and Homelike Environment dated 05/21/25 revealed the facility would provide a safe, clean, comfortable, and homelike environment. 3. Observation on 05/18/25 at 4:15 P.M. with Certified Nurse Aide (CNA) #378 revealed the floor and the walls in Resident #62's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:15 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #62's room were soiled. 4. Observation on 05/18/25 at 4:16 P.M. with CNA #378 revealed the floor and the walls in Resident #123's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:17 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #123's room were soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 2 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 5. Observation on 05/18/25 at 4:19 P.M. with CNA #378 revealed the floor and the walls in Resident #53's room were heavily soiled with an unknown black substance. The bathroom floor was heavily soiled, and there was a black ring inside the toilet bowl. Interview on 05/18/25 at 4:20 P.M. with CNA #378 confirmed the walls, floors, and toilet in Resident #53's room were soiled. 6. Observation on 05/18/25 at 4:45 P.M. with Dietary Manager (DM) #389 confirmed the resident dining room floor was heavily soiled with food debris and liquid stains. Interview on 05/18/25 at 4:45 P.M. with DM #389 confirmed the dining room staff was responsible for cleaning the dining room floor. DM #389 stated the dining staff was short staffed on 05/17/25, and the floor was not mopped after dinner or before breakfast on 05/18/25 and remained soiled throughout the day. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 3 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. 7. Review of the medical record for Resident #42 revealed the resident an admission date of 12/28/21 with diagnoses including diabetes, mood disturbance, dementia, and pressure ulcer. Residents Affected - Some Review of care plan for Resident #42 dated 01/14/22 revealed the resident had moisture associated skin damage. Review of the MDS assessment for Resident #42 dated 03/25/25 revealed the resident had severe cognitive impairment, required extensive assistance with ADLs. Review of the monthly physician's orders for Resident #42 dated May 2025 revealed the resident had a treatment order to a stage III pressure ulcer on the coccyx. Interview on 05/21/25 at 2:00 P.M. with Registered Nurse (RN) #312 confirmed Resident #42 had developed a stage III pressure ulcer to the coccyx and the resident's care plan had not been updated to reflect the resident's current skin condition. Review of the facility policy titled Care Planning dated 01/25/25 revealed the facility would make changes to the plan of care as needed. Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure care conferences were completed as required. This affected four (Residents #10, #23, #40, and #56) of five residents reviewed for care conferences. The facility failed to ensure care plans were updated following a change in condition. This affected two (Residents #10 and #48) of 19 residents reviewed for care planning. The facility census was 68. Findings include: 1. Review of the medical record of Resident #10 revealed an admission date of 09/04/21 with diagnoses including congestive heart failure (CHF), type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), depression, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 04/07/25 revealed the resident had intact cognition and required staff assistance with activities of daily living. Review of a progress note for Resident #10 dated 10/10/24 revealed the resident and her family were invited to a care conference that was scheduled for the same date as the invitation and both declined to attend. Review of the medical record for Resident #10 revealed no evidence of care conferences being held. Interview on 05/18/25 at 10:15 A.M. with Resident #10 confirmed she had not had any recent care conferences and further stated she did not know what care conferences were. Interview on 05/19/25 at 1:34 P.M. with Clinical Director (CD) #312 confirmed there was no evidence of care conferences being held for Resident #10. CD #312 stated Resident #10 refused, however verified there was no further documentation beyond the progress note dated 10/10/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 4 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the plan of care for Resident #10 dated 01/22/23 revealed the resident was at risk for complications related to the use of antipsychotic medications. The resident had bipolar disorder and major depressive disorder. Further review of the care plan revealed the plan had not been updated regarding Resident #10's diagnosis of schizoaffective disorder. Review of the diagnosis list for Resident #10 revealed the resident was diagnosed with schizoaffective disorder on 01/11/24. Interview on 05/20/25 at 12:20 P.M. with CD #312 confirmed the facility had not updated Resident #10's care plan to address the resident's new diagnosis of schizoaffective disorder on 01/11/24. 3. Review of the medical record for Resident #23 revealed an admission date of 01/25/25 with diagnoses including fracture of the left humerus, post-traumatic stress disorder, depression, and glaucoma. Review of the MDS assessment for Resident #23 dated 05/02/25 revealed Resident #23 was cognitively intact. Review of Resident #23's medical record dated June 2024 to May 2025 revealed a care conference had not been completed for the resident. Interview on 05/19/25 at 03:27 P.M. with CD #312 confirmed that there was no documentation of a care conference being held for Resident #23. 4. Review of the medical record for Resident #56 medical recorded revealed an admissions date of 08/23/23 with diagnoses including benign neoplasm of meninges, pulmonary hypertension, blindness, and arthropathy. Review of the MDS assessment for Resident #56 dated 04/11/25 revealed the resident #23 was moderately cognitively impaired. Review of medical record for Resident #56 dated June 2024 to May 2025 revealed the only care conference held for the resident during this time frame occurred on 11/21/24 and the care conference document for 11/21/24 had not been signed and dated as completed. Interview on 05/19/25 at 3:29 P.M. with CD #315 confirmed the facility only had one care conference documented for Resident #56 from June 2024 to May 2025. CD #312 confirmed the only documented care conference on 11/21/24 had not been signed and dated as complete. 5. Review of the medical record for Resident #40 revealed an admission date of 08/14/24 with diagnoses including peripheral vascular disease, diabetes mellitus (DM), essential primary hypertension, depression, and anxiety disorder. Review of the MDS assessment for Resident #40 dated 05/01/25 revealed the resident had impaired cognition and required staff assistance with ADLs. Review of the care conference note for Resident #40 dated 11/24/24 revealed there no signature or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 5 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0657 lock date to confirm the conference had been completed. Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/25 at 11:58 A.M. with Resident #40 confirmed he had never had a care conference to discuss his plan of care. Residents Affected - Some Interview on 05/20/25 12:45 A.M. with CD #312 confirmed the care conference note for Resident #40 dated 11/24/24 had not been signed or locked to indicate the conference had been completed. 6. Review of the medical record for Resident #62 revealed as admission date of 04/13/25 with diagnoses including polyneuropathy, CHF, hypertension, and acute respiratory failure with hypoxia. Review of the MDS assessment for Resident #62 dated 05/08/25 revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the medical record for Resident #62 dated June 2024 to May 2025 revealed there was no documentation of a care conference completed for the resident. Interview on 05/18/25 at 10:47 A.M. with Resident #62 confirmed she was not sure if she ever had a care conference to discuss her plan of care. Interview on 05/20/25 12:45 A.M. with CD #312 confirmed Resident #62's record did not include documentation of a care conference completed for the resident from June 2024 to May 2025. Review of the facility policy titled Care Planning-Resident Participation dated 01/25/25 revealed the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences initially, at routine intervals, and after significant changes. The facility would make an effort to schedule the conference at the best time of day for the resident/resident's representative and obtain a signature from the resident and/or representative after discussion or viewing of the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 6 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on medical record review, staff interview, review of the facility policy, and review of online guidelines per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess resident skin and failed to identify pressure ulcers until they had reached an advanced stage. This resulted in Actual Harm for Resident #40 who was admitted to the facility without pressure ulcers, was assessed to be at low risk for the development of pressure ulcers, and developed an unstageable pressure ulcer with slough (nonviable tissue which could impede wound healing) to the left buttock. This affected one (Resident #40) of three residents reviewed for pressure ulcers. The facility census was 68 residents. Residents Affected - Few Findings include: Review of the medical record review for Resident #40 revealed an admission date of 08/14/24 with diagnoses including peripheral vascular disease, diabetes mellitus (DM), hypertension, and depression. Review of the care plan for Resident #40 dated 12/04/24 revealed the resident was at risk for impaired skin integrity and breakdown related to impaired mobility. Interventions included the following: assess nutrition and hydration, encourage the resident to turn and reposition every two hours, pressure relieving cushion to wheelchair, pressure relieving mattress, provide nutritional supplements, weekly skin assessments by a licensed nurse. Review of the shower sheets for Resident #40 dated 03/08/25, 03/13/25, 03/16/25, 03/17/25,03/20/25, 03/26/25, 03/29/25, 03/31/25, 04/02/25, 04/05/25, 04/09/25, 04/22/25, and 04/26/25 revealed there was no documentation of wounds or open areas. Review of the physician's orders for Resident #40 revealed an order dated 03/17/25 for weekly skin assessments every Sunday on night shift. Review of the weekly skin assessment for Resident #40 dated 04/07/25 revealed the resident had no skin issues. Review of the medical record for Resident #40 revealed weekly skin assessments were not completed for 04/14/25, 04/21/25 or 04/28/25. Review of the weekly skin assessment for Resident #40 dated 04/30/25 revealed the nurse identified a new skin issue to the resident's buttocks which was described as moisture-associated skin damage (MASD) with scabbing. Review of the wound note for Resident #40 dated 05/01/25 per Wound Nurse Practitioner (WNP) #500 revealed the NP examined a wound to the resident's left buttock which staff first identified on 04/30/25. WNP #500 classified the wound as an unstageable, facility-acquired pressure ulcer to the resident's left buttock which measured 5.1 centimeters (cm) in length by 4.4 cm in width with a depth unable to be determined. The base of the wound was covered with 100 percent (%) slough tissue and required sharp debridement at the resident's bedside. Review of the care plan for Resident #40 dated 05/01/25 revealed the resident had impaired skin integrity related to a pressure ulcer to the buttock. Interventions included the following: administer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 7 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0686 Level of Harm - Actual harm Residents Affected - Few treatments as ordered and monitor for effectiveness, educate resident/family/and caregivers as to cause of skin breakdown including transfer/positioning requirements, good nutrition, and frequent repositioning, encourage the resident to offload bony prominences with pillows and positioning devices. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 05/01/25 revealed the resident had impaired cognition, required staff assistance with activities of daily living (ADLs), and had an unstageable pressure ulcer. Review of the dietary progress note for Resident #40 dated 05/06/25 revealed the resident had an unstageable pressure ulcer to the left buttocks with an increased need for nutrition to promote wound healing. Review of the pressure ulcer risk assessment for Resident #40 dated 05/08/25 revealed the resident was at low risk for developing pressure ulcers, had no limitation of mobility, and made frequent changes in position. Interview on 05/02/25 at 11:04 A.M. with Assistant Director of Nursing (ADON) #366 confirmed she was the facility wound nurse and made rounds weekly with WNP #500. ADON #366 confirmed a nurse first identified the wound to Resident #40's wound on left buttock on 04/30/25 and described the area as MASD but did not complete measurements or a detailed assessment at the time of identification. ADON #366 confirmed the facility failed to complete weekly skin assessments for Resident #40 on 04/14/25, 04/21/25, and 04/28/25 and did not identify Resident #40's wound until it had reached an advanced stage. Interview on 05/20/25 at 11:51 A.M. with WNP #500 confirmed the facility asked her to assess a wound to Resident #40's left buttock which was first identified on 04/30/25. WNP #500 confirmed she assessed Resident #40 on 05/01/25 and found an unstageable pressure ulcer with a wound bed which was covered 100 % with slough tissue to the resident's left buttock. WNP #500 confirmed all wounds should be considered avoidable. Interview on 05/21/25 at 4:05 P.M with Clinical [NAME] President (CVP) #312 confirmed the facility nurses should have completed a weekly skin assessment for Resident #40 and the assessments for 04/14/25, 04/21/25, and 04/28/25 were not completed. Review of the facility policy titled Wound Management Documentation dated 05/07/25 confirmed the facility should complete and document weekly wound and skin assessments. Review of the NPUAP guidelines dated 2014 pages 70-71 at https://npiap.com/general/custom.asp?page=2014Guidelines revealed facilities should educate health professionals on how to undertake a comprehensive skin assessment that included the techniques for identifying blanching response, localized heat, edema, and induration. Further review of the guidelines revealed ongoing assessment of the skin was necessary in order to detect early signs of pressure damage. Visual assessment for erythema (redness of the skin) was the first component of every skin inspection. Skin redness and tissue edema resulting from capillary occlusion was a response to pressure, especially over bony prominences. Staff should conduct a head-to-toe assessment with particular focus on skin overlying bony prominences including the sacrum, ischial tuberosities, greater trochanters and heels and each time the patient was repositioned was an opportunity to conduct a brief skin assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 8 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules, staff interview, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: Review of staffing schedules dated 04/13/25 through 05/17/25 revealed on 04/27/25 there was no RN working in the facility. Interview on 05/21/25 at 11:10 A.M. with Clinical Director (CD) #312 confirmed the facility did not have an RN working for eight consecutive hours on 04/27/25. Review of the facility policy titled Nursing Services-Registered Nurse dated 05/01/25 revealed the facility would utilize the services of an RN for at least eight consecutive hours per day, seven days per week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 9 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to properly store medications in a safe and secure manner. This affected one (Resident #62) of 19 residents sampled. The facility census was 68 residents. Findings include: Review of the medical record for Resident #62 revealed an admission date of 04/13/25 with diagnoses including polyneuropathy, congestive heart failure, hypertension, and acute respiratory failure with hypoxia. Review of the Minimum Data Set (MDS) assessment for Resident #62 dated 05/08/25, revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #62 dated May 2025 revealed no orders for cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets. Review of the Medication Administration Record (MAR) for Resident #62 dated May 2025 revealed there was no documentation of administration of the following medications: cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets. Observation on 05/18/25 at 10:52 A.M. with Licensed Practical Nurse (LPN) #400 revealed Resident #62 had the following medications/supplements in bottles on her bedside table: cranberry supplement, probiotic tablets, Refresh Tears eye drops, Replenish eye drops, Ketorolac eye drops, multivitamin capsules, and Tums tablets Interview on 05/18/25 at 10:52 A.M. with LPN #400 confirmed the medications should not be at Resident #62's bedside and should be locked in the medication cart. LPN #400 confirmed Resident #62 did not have orders for the medications and supplements listed. Review of the facility policy titled Medication Storage dated 04/28/25 confirmed the facility would ensure all medications housed on the premises would be stored in medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Further review of the policy revealed all drugs and biologicals would be stored in locked compartments, medication carts, cabinets, drawers, or refrigerators. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 10 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on medical record review, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure resident meal preferences were honored. This affected one (Resident #23) of 19 residents sampled. The facility census was 68 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 01/25/25 with diagnoses including fracture of the left humerus, post-traumatic stress disorder, depression, and glaucoma. Review of the Minimum Data Set assessment for Resident #23 dated 05/02/25 revealed the resident was cognitively intact. Review of the lunch order for Resident #23 dated 05/19/25 revealed the resident ordered a hot dog, mashed potatoes and fruit. Interview on 05/18/25 at 10:08 A.M. with Resident #23 confirmed she often did not receive what was written on the menu and would receive a peanut butter and jelly sandwich instead. Observation service on 05/19/25 at 12:59 P.M. of the lunch service revealed Resident #23 received mashed potatoes, fruit, and a peanut butter sandwich. Interview on 05/19/25 at 12:59 P.M. with Resident #23 confirmed she received a peanut butter sandwich for an entrée instead of the hot dog she had ordered. Interview on 05/19/25 at 1:00 P.M with Director of Nutritional Services (DNS) #389 confirmed Resident #23 had ordered a hot dog as an entrée for lunch but instead received a peanut butter sandwich. DNS #389 confirmed when the kitchen did not have an ordered item available, a staff member should discuss other options with the resident. Further interview with DNS #389 confirmed the kitchen staff were busy, and a staff member had not discussed alternative menu options with the resident since hot dogs were not available. DNS #389 verified that the kitchen staff assumed Resident #23 would want a peanut butter sandwich without verifying this with the resident. Review of the facility policy titled Standardized Menus dated 05/01/25 revealed that the facility would support resident's rights to make personal dietary choices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 11 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was prepared, stored, and served in a manner to protect against foodborne illness. This had the potential to affect all of the residents residing in the facility. The facility identified one (Resident #37) who did not receive food from the kitchen. The facility census was 68 residents. Findings include: 1. Observation on 05/18/25 at 8:36 A.M. of the breakfast tray line revealed Certified Nursing Assistant (CNA) #362 was assisting with food preparation by covering plates, adding drinks to trays, and placing trays on a cart. CNA #362 was not wearing a hair net. Interview on 05/18/25 at 8:50 A.M. with CNA #362 confirmed she was assisting with tray line and was not wearing a hair net. CNA #362 stated she was trying to stay away from the steam table so she wouldn't have to wear a hairnet. 2. Observation on 05/18/25 at 8:40 A.M. revealed there were several black specks, measuring approximately one-quarter of inch on the floor between the deep fryer and stove and on the rack below the steamer. Interview on 05/18/25 at 8:57 A.M. with Dietary Staff (DS) #392 confirmed there were black specks on the floor between the deep fryer and stove and on the rack below the steamer. DS #392 stated the black specks were mouse droppings. 3. Observation on 05/18/25 at 8:40 A.M. revealed there were two windows in the kitchen which were open. Further observation revealed the screen on one of the windows was damaged and had a hole, which measured approximately one inch by one inch. Interview on 05/18/25 at 8:55 A.M. with DS #392 confirmed the windows were open and one of the screens was damaged. 4. Observation on 05/18/25 at 8:48 A.M. with DS #392 revealed the reach-in cooler contained the following items: strips of cooked bacon, wrapped in plastic with no label or date, a ham and cheese sandwich on a plate, wrapped in plastic wrap, with no label or date, four fruit plates with tuna salad, each wrapped in plastic wrap, with no label or date, a large plastic bin of tuna salad, covered, with no label or date, a tray with nine individual cups of Italian dressing with a label which read pears undated, three supplement shake cartons, unopened, dated 04/04/25, a tray with seven individual cups of shredded cheese, with no label or date, six hard-boiled eggs, wrapped in plastic wrap, with no label or date, a bag of shredded cheese, wrapped in plastic wrap, with no date, a pan of hamburgers, covered in foil with no label or date, a pan of olives, covered in plastic wrap dated 05/01-05/07. Interview on 05/18/25 at 8:48 A.M. with DS #392 confirmed the food items in the reach-in cooler were not labeled and/or dated appropriately and the supplement shakes were outdated. 5. Observation on 05/18/25 at 8:53 A.M. with DS #392 revealed the reach-in freezer contained the following opened, unlabeled, undated, and unsealed items: a box of roll dough, box of biscuit dough, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 12 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0812 and a box of frozen broccoli. Level of Harm - Minimal harm or potential for actual harm Interview on 05/18/25 at 8:53 A.M. with DS #392 confirmed the rolls, biscuits, and broccoli in the reach-in freezer were not sealed, labeled, or dated. Residents Affected - Many 6. Observation on 05/18/25 at 8:58 A.M. with DS #392 revealed there was a foul odor inside the walk-in cooler. There was a large puddle of a reddish-brown liquid on the floor which measured approximately eight by eight inches below an empty cart. Interview on 05/18/25 at 8:58 A.M. with DS #392 confirmed the odor and puddle beneath the cart in the walk-in cooler were due to meat that had recently been thawed and attributed the foul odor to the liquid remaining on the floor. DS #392 was unsure long the puddle of liquid had been there or when the meat had been removed from the cooler. 7. Observation on 05/18/25 at 9:00 A.M. with DS #392 revealed the walk-in freezer contained the following opened, unlabeled, and undated items: a bag of strawberries, a bag of french fries. Interview on 05/18/25 at 9:00 A.M. with DS #392 confirmed the strawberries and the french fries in the walk-in freezer were not labeled or dated appropriately. 8. Observation on 05/18/25 at 9:02 A.M. with DS #392 revealed the dry storage area contained the following items: a box containing a plastic jug of oil, stored directly on the floor, four bags of pasta, opened and wrapped in plastic wrap with no label or date, a bag of cream soup base, opened and wrapped in plastic wrap with no label or date, bins of flour and breadcrumbs with no label or date. Interview on 05/18/25 at 9:02 A.M. with DS #392 confirmed the oil in the dry storage area was stored on the floor and the pasta, cream soup base, flour, and breadcrumbs were not labeled or dated appropriately. 9. Observation on 05/18/25 at 9:08 A.M. with DS #392 revealed there were three dark brown insects each measuring approximately two inches in length on the floor by the dry storage area. Interview on 05/18/25 at 9:10 A.M. with DS #392 confirmed there were three dark brown insects on the floor near the dry storage area. 10. Observation on 05/18/25 at 12:26 P.M. revealed CNA #500 served Resident #19 her lunch and touched the bun of the resident's sandwich with his bare hands. Interview on 05/18/25 at 12:28 P.M. with CNA #500 confirmed he touched Resident #19's food with his bare hand and he should have been wearing gloves when handling resident food. 11. Observation on 05/18/25 at 12:28 P.M. revealed CNA #349 assisted Resident #48 and picked up the resident's sandwich with her bare hands. Interview on 05/18/25 at 12:30 P.M. with CNA #349 confirmed she handled Resident #48's sandwich with her bare hands. 12. Observation on 05/19/25 at 10:05 A.M. with Dietary Manager (DM) #389 revealed the vents of the oven hood were caked with a fuzzy white substance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 13 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0812 Level of Harm - Minimal harm or potential for actual harm Interview on 05/19/25 at 10:05 A.M. with DM #389 confirmed the vents of the oven hood were caked with a white and fuzzy substance. 13. Observation on 05/19/25 at 10:09 A.M. revealed DS #321 unloaded clean plates from a plastic rack, which had just been run through the dishwasher and used a rag to dry the plates. Residents Affected - Many Interview on 05/19/25 at 10:09 A.M. with DS #321 confirmed she was drying the plates which had just been washed using a rag. 14. Observation on 05/19/25 at 10:50 A.M. revealed DM #389 prepared pureed chicken for the lunch meal and used a spatula which had a burnt and blackened section which measured approximately one-half to remove the chicken from the blender. There were two additional spatulas hanging in the food preparation area which also had blackened and burnt areas on them. Interview on 05/19/25 at 10:51 A.M. with DM #389 confirmed the spatula utilized to scrape the chicken out of the blender had a burnt and blackened section. Review of the facility policy titled Date Marking for Food Safety dated 05/19/25 revealed food should be clearly marked to indicate the date or day by which the food should be consumed or discarded. The discard date might not exceed the manufacturer's use-by date Review of the facility policy titled Food Safety Requirements dated 05/22/25 revealed food should be stored off the floor, gloves should be used when touching and assisting with ready-to-eat foods, all equipment used in the handling of food should be clean and sanitized, and staff should wear hairnets when cooking, preparing, or assembling food. Review of the facility policy titled Sanitation Inspection dated 05/19/25 revealed all food service areas shall be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 14 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and review of the facility policy, the facility failed to ensure garbage cans in the kitchen were covered. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Residents Affected - Many Findings include: Observation on 05/18/25 at 8:40 A.M. revealed there were two garbage cans in the food preparation area which had no covers Interview on 05/18/25 at 8:52 A.M. with Dietary Staff (DS) # 392 confirmed the garbage cans were not covered. Observation on 05/19/25 at 10:05 A.M. revealed the two garbage cans in the food preparation remained uncovered. Review of the facility policy titled Disposal of Garbage and Refuse dated 05/21/25 revealed garbage and refuse containers should be covered when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 15 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to maintain a safe, functional, and sanitary environment in the common areas of the facility. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Findings include: 1.Observation on 05/18/25 at 4:55 P.M. revealed the cove base in the entrance to the rehab hallway was ripped and torn. There were also multiple missing floor tiles. Interivew on 05/18/25 at 4:55 P.M. with Certified Nursing Assistant (CNA) #377 confirmed the cove base to the walls near the entrance to the rehab unit was ripped and torn and there were multiple missing floor tiles. CNA #377 confirmed the floor was in disrepair and presented a trip hazard to residents, staff, and visitors. 2. Observation on 05/21/25 at 3:23 P.M. with Maintenance Supervisor (MS) #307 revealed the ceiling light to the entrance of the rehab unit was not working and the cover to the light fixture was broken. Interview on 05/21/25 at 3:23 P.M. with MS #307 confirmed the ceiling light to the entrance of the rehab unit was in a state of disrepair. 3. Observation on 05/21/25 at 3:25 P.M. with MS #307 revealed the ceiling vents on the Sea Side Lane unit were dusty with debris hanging down from them. Interview on 05/21/25 at 3:37 P.M. with MS #307 confirmed the ceiling vents on the Sea Side Lane unit were dusty with debris hanging down from them. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 16 of 17 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 366178 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Widows Home of Dayton 50 South Findlay Street Dayton, OH 45403 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of pest control documentation, and policy review, the facility failed to maintain effective pest control in the kitchen area. This had the potential to affect all of the residents residing in the facility. The facility census was 68 residents. Residents Affected - Many Findings include: 1. Observation on 05/18/25 at 8:40 A.M. revealed there were several black specs, measuring approximately one quarter inch on the floor between the deep fryer and stove and on the rack below the steamer. Interview on 05/18/25 at 8:57 A.M. with Dietary Staff (DS) #392 confirmed the black specs on the floor between the deep fryer and stove and on the rack below the steamer were mouse droppings. 2. Observation on 05/18/25 at 9:08 A.M. on the floor by the dry storage area revealed there were three cockroaches measuring approximately two inches in length. Interview on 05/18/25 at 9:10 A.M. with DS #392 confirmed there were three dark brown insects on the floor by the dry storage area. Review of pest control documentation revealed the kitchen had been treated for routine monthly services on 01/20/25, 02/14/25, 03/14/25, and 04/11/25 with no issues were noted at the time of the visits. Review of the facility policy titled Sanitation Inspection dated 05/19/25 revealed all food service areas should be kept clean, sanitary, and protected from rodents, roaches, flies, and other insects. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366178 If continuation sheet Page 17 of 17