Health inspection·February 6, 2024

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 record review, observations, staff and pharmacy interviews and policy review, the facility failed to ensure medications were administered as ordered. This affected two (#30 and #60) of three residents reviewed for medication administration. Facility census was 68. Findings include: 1. Review of medical record for Resident #30 revealed admission date of 01/17/23 with a Brief Interview Mental Status (BIMS) score of 13 on 01/11/24 indicating intact cognition. Diagnoses include chronic obstructive pulmonary disorder, heart failure, schizophrenia, depression, dementia with psychotic disturbances and insomnia. Resident #30 remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed he required set up for meals, dependent for bathing, toileting and substantial assistance for bed mobility. Observation on 01/23/23 at 10:10 A.M. of medication pass by Assistant Director of Nursing (ADON) #117 for Resident #30 revealed Potassium Chloride (hypokalemia) packet 10 Milliequivalent (MEQ) was not available for administration. ADON #117 was unable to answer when and or if the medication had been reordered. Interview on 01/24/24 at 12:11 P.M. with Pharmacy Clinical Director (PCD) #120 revealed the pharmacy received an order for Potassium Chloride 10 MEQ oral packet daily on 01/11/14 and they contacted the facility for clarification as the packet medication did not come in that strength. PCD #120 stated the facility did not provide a clarification and verified no 10 MEQ Potassium Chloride packet was delivered to the facility. Interview on 01/25/24 at 10:58 A.M. with the DON and Clinical Corporate Registered Nurse #121 the incorrect dosage of Potassium Chloride was documented as given to Resident #30 during the period of 01/11/24 through 01/22/23. Further record review of the progress notes 01/24/2024 at 4:23 P.M. revealed the DON and ADON #117 contacted family that Resident #30 had received the incorrect strength of Potassium Chloride. During the period of 01/11/24 through 01/22/24 Resident #30 was given 20 MEQ instead of 10 MEQ in error with no adverse effects. Record review of the January Medication Administration Record (MAR) revealed Potassium Chloride Packet 10 MEQ was charted as given on 01/12/24, 01/13/24, 01/14/24, 01/15/24, 01/16/24, 01/17/24, 01/19/24, 01/20/24 and 01/22/24. 2. Review of medical record for Resident #60 revealed admission date of 12/08/23. Diagnoses include chronic obstructive pulmonary disorder and Parkinson's disease. Resident #60 remains in the facility. Review of the physician orders revealed an order for Symbicort 80.0-4.5 mcg/act, two puffs two times a day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366400 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 366400 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Health and Rehab 3854 Park Overlooke Drive Beavercreek, OH 45431 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 Observation on 01/23/24 at 8:26 A.M. of Licensed Practical Nurse (LPN) # 100 for Resident #60 revealed her prescribed Symbicort (inhaler) 80.0-4.5 micrograms per (/) actuation (mcg/act) was not in the medication cart. LPN #100 stated the medication was given the evening of 01/22/24 and was previously reordered. LPN #100 verified she would contact the Nurse Practitioner to inform the medication was unavailable. Residents Affected - Few Interview on 01/23/24 at 11:11 A.M. with Pharmacy Technician #106 revealed Symbicort had not been reordered until 01/23/24. Review of the facility policy Medication Administration, dated 10/01/22 documented to compare the medication source with MAR to verify resident name, medication name, form dose, route and time. This deficiency represents non-compliance investigated under Complaint Number OH00150026 and OH00149574. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366400 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 366400 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Beavercreek Health and Rehab 3854 Park Overlooke Drive Beavercreek, OH 45431 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital documentation and staff interview, the facility failed to ensure documentation regarding nursing assessments and/or the circumstances surrounding a residents hospitalization was documented in the medical record. This affected one (#84) of three residents medical records reviewed for hospitalization. Facility census was 68. Findings include: Review of medical record for Resident #84 revealed admission date of 04/26/23. Diagnoses include femur fracture and hypertension. Resident #84 was discharged from the facility to the hospital on [DATE]. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #84 required extensive assistance for bed mobility, toileting, transfers occurred only once or twice and eating required supervision. The MDS documented Resident #84 was discharged to an acute hospital. Record review of the progress notes for Resident #84 revealed there was no documentation for his hospitalization, and/or him leaving the facility. Further review of physician notes revealed no documentation of his hospitalization or discharge information. Further review of hospital records revealed Resident #84 presented to the emergency room with postoperative right hip pain that is chronic. The hip is not infected, the leg is neurovascularly intact, the hardware looks to be intact. Resident #84 reported the pain worsened last night. Resident #84 states that his family was the one to call the squad today because of his increase in pain which he describes as a gradual onset of constant, waxing and waning in severity, moderate to severe, sharp pain over his right hip. Resident #84 was admitted to the hospital related to the right hip pain. Interview on 01/25/24 at 8:42 A.M. with Clinical Corporate Registered Nurse #119 verified there was no documentation including nursing assessments and/or the circumstances regarding the hospitalization of Resident #84. Interview on 01/25/24 at 12:30 P.M. with Assistant Director of Nursing (ADON) #117 verified there was no documentation regarding the discharge of Resident #84 and added he did not recall any specifics regarding his discharge. Interviews on 01/25/24 at 1:15 P.M. with Social Services Designee SSD#103 revealed she recalled Resident #84 was sent to the hospital but did not recall why, nor could she recall any follow up from the hospital. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366400 If continuation sheet Page 4 of 4