Inspection·February 6, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident had left the dining room, that residents have the right to choose menu items despite dietary restrictions. Interview on 02/05/25 at 2:13 P.M. with Resident #19 confirmed she wanted to have meatloaf like everyone else got for lunch. Resident #19 confirmed she had told kitchen staff on multiple occasions that she did not like chicken. Interview on 02/05/25 at 2:30 P.M with LPN #302 confirmed she was not overly familiar with Resident #19's diet but supported DA #404's statement that meatloaf was not on the resident's diet. LPN #302 confirmed residents had the right to self-determination and that all residents have the right to make choices. Interview on 02/05/25 at 3:03 P.M. with the DON confirmed the residents had the right to make their own choices and Resident #19 should have been able to substitute meatloaf for the chicken on her lunch tray. Interview with Director of Clinical Operation (DCO) # 422 on 02/05/25 at 3:15 P.M. confirmed DA #404 was mistaken, and meatloaf was permitted on the consistent-carbohydrate diet. Review of the facility policy titled Resident Rights undated revealed staff would respect resident choices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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 stored and served in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 of 111 residents. The facility identified three (Residents #37, #172, and #169) who did not receive food from the kitchen. The facility census was 111 residents. Findings include: 1. Observation on 02/03/25 at 9:15 A.M. of the facility's dry storage area revealed the following items: an opened undated bag of baking powder wrapped in plastic wrap, an opened bag of marshmallows wrapped in plastic wrap dated 08/20/23, an opened 12 quart plastic container of chocolate chips with an open date of 12/10/24 and discard date of 01/10/25, an opened undated bag of egg noodles wrapped in plastic wrap, a cardboard box containing a jug of oil stored directly on the floor, a box of bananas which were brown with several gnats flying around the immediate vicinity, an undated bag of cake mix wrapped in plastic wrap, a large bin of flour dated 03/26/24, four large plastic containers of cereal with open dates of 01/03/25 and discard dates of 01/10/25. Interview on 02/03/25 at 9:15 A.M. with Account Manager (AM) #410 confirmed the oil should not be stored directly on the floor. AM #410 stated the bananas were for the activity department and verified the gnats around them. AM #410 confirmed the marshmallows should have been discarded because they were outdate. AM #410 verified the baking powder, noodles, and cake mix should have been labeled and dated. AM #410 verified the chocolate chips, flour, and cereal were all outdated and should have been discarded by the dates on each product. 2. Observation on 02/03/25 at 9:20 A.M. revealed Dietary Aide (DA) #404 was using a black marker and writing the date 01/03/25 on four plastic bins containing dry cereal. Interview on 02/03/25 at 9:20 A.M. with DA #404 confirmed they wrote the date 01/03/25 on four plastic bins of dry cereal which had already been opened prior to the survey. Interview on 02/03/25 at 9:20 A.M. AM #410 confirmed the cereal had already been opened at an undetermined time prior to the survey observation and food items should be dated at the time of opening. 3. Observation on 02/03/25 at 9:21 A.M. revealed the following items were being stored in the facility's walk-in refrigerator: an undated, unlabeled pan of hotdogs loosely covered in plastic wrap, an undated, unlabeled pan of hamburgers loosely covered in plastic wrap, a brick of American cheese slices dated 01/10/25, an undated, unlabeled bag of parmesan cheese. Interview on 02/03/25 at 9:21 A.M. with AM #410 confirmed the hamburgers and hotdogs were not tightly sealed nor labeled, the American cheese slices were outdated, and the bag of parmesan cheese was not labeled. 4. Observation on 02/05/25 at 12:59 P.M. revealed staff loaded lunch trays onto cart which had a pink and sticky substance on the bottom of the cart. Interview on 02/05/25 at 12:59 P.M. with AM #410 confirmed there was a pink and sticky substance on the bottom of the cart, and the carts were supposed to be wiped down daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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 5. Observation on 02/05/25 at 1:05 P.M. during tray line revealed DA #407 reached for a hamburger bun from a bag of buns with a gloved hand. DA #407 then opened the door to the oven, retrieved a foil package, took a veggie burger out of the package, and placed the burger on a bun all while utilizing the same gloved hand. Interview on 02/05/25 at 1:06 P.M. with DA #407 confirmed he verified touched the burger with his gloved hand after touching oven handles. Observation on 02/05/25 at 1:06 P.M. revealed Director of Clinical Operations (DCO) #411 instructed DA #407 to remove the gloves and use serving utensils instead. 6. Observation on 02/05/25 at 1:19 P.M. during tray line revealed DA #407 retrieved a veggie burger from the oven and placed it on a bun using his bare ungloved hand. Interview on 02/05/25 at 1:19 P.M. with DA #407 confirmed he had handled the veggie burger with his bare hand. 7. Observation on 02/05/25 at 1:23 P.M. revealed another cart being utilized to load lunch trays during tray line had a sticky white substance in the bottom center. Interview on 02/05/25 at 1:23 P.M. with [NAME] #409 confirmed there was a white sticky substance on the bottom of the cart which was being utilized for clean lunch trays. 8. Observation on 02/05/25 at 3:45 P.M. revealed the refrigerator on the Applewood unit contained the following items: an opened carton of half and half with a use-by date of 01/13/25, three undated containers of orange juice, an opened unlabeled, undated bottle of pink lemonade, two bags of opened undated shredded cheese, multiple areas of a brown, sticky substance in the door of the refrigerator. Observation of the freezer compartment of the refrigerator on the Applewood unit revealed it contained three undated popsicles which appeared to be freezer-burnt. Interview on 02/05/25 at 3:45 P.M. with the Director of Nursing (DON) confirmed the half and half, the orange juice, the pink lemonade, the cheese, and the popsicles were not stored appropriately. The DON further confirmed there was a brown and sticky substance in the door of the refrigerator. 9. Observation on 02/05/25 at 3:50 P.M. revealed the refrigerator on the Elm unit contained the following items: six undated containers of orange juice, four undated containers of apple juice, and an opened and undated container of caramel syrup. Interview on 02/05/25 at 3:50 P.M. with the DON confirmed the juices and caramel syrup should have been dated. Review of the facility policy titled Food Storage: Cold Foods dated April 2018 revealed all foods would be stored six inches above the floor and all foods would be stored, wrapped, or in covered containers and labeled and dated. Review of the facility policy titled Environment dated September 2017 revealed all food service and preparation areas would be maintained in a clean and sanitary condition. This deficiency represents noncompliance investigated under Complaint Number OH00161232. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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. Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff documented medication administration accurately in the electronic medical record. This affected one (Resident #99) of five residents reviewed for unnecessary medications. The facility census was 111 residents. Findings include: Review of the medical record of Resident #99 revealed an admission date of 05/10/24 with diagnoses including acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, chronic atrial fibrillation, chronic obstructive pulmonary disease, hypertension (HTN), and heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #99 dated 12/02/24 revealed the resident had intact cognition and required staff assistance with activities of daily living (ADLs.) Review of physician's orders for Resident #99 revealed an order dated 12/14/24 for metoprolol tartrate 25 mg give one half tablet by mouth two times per day for HTN and an order dated 01/22/25 to increase the metoprolol tartrate to 25 mg one tablet by mouth two times a day for HTN. Both metoprolol orders had parameters to hold the medication for a systolic blood pressure less than 110. Review of the Medication Administration Record (MAR) for Resident #99 dated January 2025 revealed metoprolol was documented as administered on the following dates and times when the resident's systolic BP was less than 110: on 01/01/25 at bedtime for a BP of 105/76, on 01/03/25 at bedtime for a BP of 100/74, on 01/06/25 at bedtime for a BP of 106/64. Review of a progress note for Resident #99 dated 01/03/25 timed at 9:18 P.M. revealed the metoprolol was held. Review of the physician's orders for Resident #99 revealed an order dated 12/17/24 for midodrine 5 mg one tablet three times a day for low blood pressure (BP) with parameters to hold the medication for a systolic BP greater than 110. Review of the MAR for Resident #99 dated January 2025 revealed midodrine was documented as administered on the following dates and times when the resident's systolic BP was greater than 110: on 01/02/25 in the afternoon for a BP of 121/77, on 01/03/25 in the afternoon for a BP of 119/68, on 01/04/25 in the morning for a BP of 127/78, on 01/04/25 in the afternoon for a BP of 127/78, on 01/04/25 in the evening for a BP of 122/70, on 01/05/25 in the morning for a BP of 128/78, on 01/05/25 in the afternoon for a BP of 122/73, on 01/05/25 in the evening for a BP of 127/25, on 01/08/25 in the afternoon for a BP of 119/77, on 01/09/25 in the afternoon for a BP of 124/66, on 01/09/25 in the evening for a BP of 127/75, on 01/10/25 in the evening for a BP of 120/80, on 01/14/25 in the afternoon for a BP of 148/85, on 01/18/25 in the afternoon for a BP of 135/89, on 01/18/25 in the evening for a BP of 129/78, on 01/20/25 in the afternoon for a BP of 136/75, on 01/22/25 in the evening for a BP of 157/98, on 01/26/25 in the morning for a BP of 132/67, on 01/30/25 in the afternoon for a BP of 125/79. Review of progress notes for Resident #99 dated 01/02/25 at 11:34 A.M., 01/09/25 at 11:31 A.M., and 01/20/25 at 12:15 P.M. revealed the resident's midodrine was held. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365081 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 365081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Rivers Healthcare Center 7800 Jandaracres Drive Cincinnati, OH 45248 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 Review of the MAR for Resident #99 dated January 2025 revealed on 01/04/25 and 01/26/25 in the morning the resident received both midodrine and metoprolol. Interview on 02/03/25 at 1:04 P.M. with Resident #99 confirmed the nurses had tried to give him midodrine at inappropriate times when his blood pressure was too high for midodrine to be administered. Residents Affected - Few Interview on 02/06/25 at 1:24 P.M. with Regional Director of Clinical Operations (RDCO) #500 confirmed Resident #99's MAR revealed staff had documented administration of metoprolol and midodrine inappropriately and not in accordance with physician order parameters on multiple dates and times. RDCO #500 further confirmed staff documented administration of both midodrine and metoprolol at the same time on 01/04/25 and 01/26/25. Interviews on 02/06/25 at 2:52 P.M. with Licensed Practical Nurse (LPN) #244 and on 02/06/25 at 3:09 P.M. with Registered Nurse (RN) #401 confirmed they documented in error the administration of metoprolol and midodrine for Resident #99 on multiple dates in January 2025 outside of the physician-ordered parameters. LPN #244 and RN #401 further denied administration of both metoprolol and midodrine at the same time to Resident #99. Review of the facility policy titled Medication Administration undated, revealed medication should only be administered as prescribed by the provider, medications will be charted when given, medications that are refused or withheld will be documented, and documentation of medications will follow accepted standards of nursing practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365081 If continuation sheet Page 6 of 6