Inspection·October 3, 2024

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy titled, Restraint, dated 06/20/15, stated the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraint use is to enhance the quality of resident life of resident by assuring safety while promoting an optimal level of function. Stated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The policy stated the need of each resident for restraint use would be assessed upon admission and as needed, a physician's order would be obtained, informed consent for the physical restraint would be obtained from the resident or legal representative. The policy stated a restraint assessment shall be used for the initial and ongoing assessments. Event ID: Facility ID: 366466 If continuation sheet Page 2 of 6 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place as per comprehensive care plan. This affected one (#77) of four residents reviewed for falls. The facility census was 114. Findings include: Review of the medical record for Resident #77 revealed an admission date of 07/27/22, with medical diagnoses of polyneuropathy, arthritis, Alzheimer's disease, hypertension, atrial fibrillation, and chronic kidney disease. Review of Resident #77's annual Minimum Data Set (MDS) assessment, dated 06/27/24, indicated Resident #77 had moderate cognitive impairment and required supervision with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #77 required partial/moderate assistance with bathing and was independent with eating. The MDS indicated Resident #77 had a history of falls. Review of Resident #77's fall care plan, dated 08/04/22, stated Resident #77 was at risk for falls and had a history of falls with fracture. The fall care plan which indicated Resident #77 had the following fall interventions in place: call light within reach, non-skid strips in front of toilet, visual reminders on walls to remind resident to call for help, visual reminders to bathroom door, and non-skid socks. Observation on 10/02/24 at 8:52 A.M., of Resident #77's room revealed the room did not have non-skid strips to bathroom floor in front of the toilet. The observation also revealed Resident #77's room did not have any visual reminders posted in the room or bathroom. Interview on 10/02/24 at 8:55 A.M., with State Tested Nursing Assistant (STNA) #20 confirmed Resident #77's room did not have non-skid strips in front of the toilet or visual reminders posted in the room or bathroom. Review of the policy titled, Fall Management, dated 10/17/16, stated a plan would be identified and implemented as necessary to protect the resident and/or other from recurrence. The policy stated the care plan is developed as necessary to reflect the resident's safety status, needs, and interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 If continuation sheet Page 3 of 6 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on medical record review, observation, staff and resident interviews, and review of hospital documentation, and policy review, the facility failed to ensure a percutaneous endoscopic gastrostomy tube (PEG) was intact and functioning properly. This affected one (#103) of five residents reviewed for nutrition. The facility census was 114. Findings include: Review of the medical record for Resident #103 revealed an admission date of 10/27/23, with medical diagnoses of amyotrophic lateral sclerosis (ALS), tracheostomy, dependence on ventilator, gastrostomy, atrial fibrillation, and chronic obstructive pulmonary disease. Review of Resident #103's quarterly Minimum Data Set (MDS) assessment, dated 08/02/24, indicated Resident #103 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene, bathing, and bed mobility. The MDS revealed Resident #103 was not transferred out of bed and had a PEG tube for enteral feedings. Review of Resident #103's physician order dated 09/23/24, revealed to flush the PEG tube with 250 milliliters (ml) with water three times per day and an order dated 10/01/24, to send resident non-emergent transport to hospital with PEG tube replacement. Observation with interview, on 10/01/24 at 9:00 A.M., revealed Registered Nurse (RN) #104 prepare Resident #103's PEG tube for medication administration. The observation revealed medical tape to be wrapped around the top portion of Resident #103's PEG tube. The observation revealed the medical tape to be slightly soiled with light brown substance around the edges. Interview on 10/01/24 at 9:02 A.M., with Resident #103 stated the tape was placed on her PEG tube because the PEG tube had a break or hole in the tubing. Resident #103 stated the PEG tube was leaking so staff taped the broken area. Resident #103 stated she was not sure how long the tape had been on her PEG tube but had been there for awhile and that facility staff were aware that there was a hole in the PEG tubing. Resident #103 stated staff would pinch off the tubing when administering flushes and medications and not use the clamp provided on the PEG tube which caused the break in the tube. Interview on 10/01/24 at 9:06 A.M., with RN #104 confirmed Resident #103's PEG tube had medical tape wrapped around the tube and the tape had been there for several days but not sure how long. RN #104 stated she was not aware of any concerns with the PEG tube leaking or having a hole in the tubing. Interview on 10/02/24 at 9:09 A.M., with RN #84 confirmed she had taken care of Resident #103 several days prior to interview and confirmed Resident #103 had medical tape wrapped around her PEG tube. RN #84 stated she thought Resident #103 returned from the hospital with the PEG tube wrapped with medical tape but was not sure. RN #84 stated she did not notice the PEG tube leaking. Review of Resident #103's nurse note dated 10/01/24 at 9:57 A.M., stated the nurse was made aware by the nurse on the floor that the resident's PEG tube was noted to be leaking. The note stated Resident #103 was noted with PEG tube and unable to be replaced in house. Further review of the nurses note stated Resident #103 was sent to the hospital for PEG tube placement and daughter was made aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 If continuation sheet Page 4 of 6 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review, of the nurse's notes revealed a note dated 10/02/24 at 1:57 A.M., which stated Resident #103 returned to the facility with new PEG tube placed in abdomen with redness and scant drainage noted. Review of the hospital emergency room (ER) note, dated 10/01/24, stated Resident #103 was seen in the ER for PEG tube malfunction. The note stated Resident #103's PEG tube was noted to have a crack toward the end of the tube and tape was wrapped around the tube. The ER stated Resident #103's PEG was replaced. Review of the policy titled, Enteral Tube Feeding, dated 06/11/24, stated it was the practice of this facility was to provide enteral nutrition as prescribed and in accordance with current clinical standards of practice. The policy stated to monitor resident for complication including, but not limited to, nausea, vomiting, diarrhea, abdominal cramping, inadequate nutrition or aspiration and to notify healthcare provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 If continuation sheet Page 5 of 6 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 366466 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Austin Trace Health and Rehabilitation 250 West Social Row Road Centerville, OH 45458 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 and resident interviews, and policy review, the facility failed to ensure medications were consumed at the time of administration and not left unsecured at the bedside. This affected one (#103) of three residents reviewed for medication administration. The facility census was 114. Findings include: Review of the medical record for Resident #103 revealed an admission date of 10/27/23, with medical diagnoses of amyotrophic lateral sclerosis (ALS), tracheostomy, dependence on ventilator, gastrostomy, atrial fibrillation, and chronic obstructive pulmonary disease. Review of Resident #103's quarterly Minimum Data Set (MDS) assessment, dated 08/02/24, indicated Resident #103 was cognitively intact and required substantial/maximum staff assistance with toilet hygiene, bathing, and bed mobility. The MDS revealed Resident #103 was not transferred out of bed and had a percutaneous endoscopic gastrostomy tube (PEG tube) for enteral feedings. Review of the medical record for Resident #103 revealed no documentation to support a physician order that medications could be left at Resident #103's bedside. Observation with interview on 10/01/24 at 9:06 A.M., of Registered Nurse (RN) #104 administer medications to Resident #103 revealed three medication cups with four white medication tablets inside sitting on Resident #103's bedside table. RN #104 stated she did not know what the medications were sitting in the medications cups and that she was not sure how long the medications were left at her bedside. Observation revealed RN #104 remove the medication cups with the four white medications tablets and discard in the biohazard bin. Interview on 10/01/24 at 9:08 A.M., with Resident #103 confirmed the three medication cups with four white medication tablets had been sitting on her bedside table and she did not know what the medications were in the medication cups. Resident #103 stated the medications had been sitting on the bedside table for a few days. Review of the policy titled, Medication Administration, effective 06/21/17, stated the facility staff are to administer medication and remain with the resident while the medication is swallowed and to never leave a medication in the resident's room without orders to do so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366466 If continuation sheet Page 6 of 6