Inspection·August 23, 2018

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diagnoses included dementia with behavioral disturbance, schizophrenia, pseudobulbar affect, seizure disorder, and cerebral infarction. Resident #122 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the quarterly MDS assessment, dated 08/03/18, revealed Resident #122 had severely impaired cognitive skills for daily decision making. Extensive assistance was required with bed mobility, transfers, toileting, and personal hygiene. Observation on 08/21/18 at 9:26 A.M. revealed Resident #122 had a yellow plastic hospital bracelet with black bold print which read FALL RISK present on the left wrist. Observation on 08/22/18 at 9:55 A.M. revealed Resident #122 was in bed asleep. Two plastic hospital bracelets were observed on the left wrist. One was the yellow fall risk bracelet and there was also a red bracelet. Observation on 08/23/18 at 1:37 P.M. revealed Resident #122 was transported back to the unit from the dining room. Both plastic hospital bracelets were visible on the left wrist. The red plastic bracelet had allergies in small black letters, but did not contain any other information. Interview on 08/23/18 at 1:43 P.M., LPN #44 reported the yellow and red plastic bracelets on Resident #122's wrist were hospital bracelets which hadn't been removed upon return to the facility. LPN #44 reported she had not attempted to remove the bracelets. Interview on 08/23/18 at 3:20 P.M., the Administrator reported the facility did not utilize plastic medical identification bracelets. The Administrator verified Resident #122 was last hospitalized on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 2 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, review of Self-Reported Incidents, and review of facility policy, the facility failed to follow their policy to report an allegation of resident to resident physical and verbal abuse to the State Survey Agency. This affected one (#98) of one resident reviewed for abuse. The facility census was 126. Residents Affected - Few Findings include: Review of the medical record revealed Resident #98 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, chronic kidney disease, hypertension, hypothyroidism, mood disorder, major depressive disorder and anemia. Review of Resident #98's Minimum Data Set (MDS) assessment, dated 07/25/18, revealed the resident to have moderate cognitive impairment. Resident #98 required supervision with eating and extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. Interview on 08/20/18 at 10:44 A.M., Resident #98 reported her roommate, Resident #56, calls her derogatory names daily. Resident #98 also reported Resident #56 hit her and tried to strangle her with the curtains. Resident #98 reported staff were aware of the allegation of physical and verbal abuse. Review of Resident #98's progress note dated 08/16/18 revealed resident alleged her roommate, Resident #56 had hit her and called her names. Director of Social Services (DSS) #26, Unit Coordinator #114, and Resident #98's power of attorney (POA) were present at the time Resident #98 made the allegation of verbal and physical abuse. Further review of the progress note dated 08/16/18 revealed the allegation was investigated and was unfounded. Resident #98 was also offered and declined a room change. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, dementia, chronic pain, hypertension, major depressive disorder, muscle weakness, retention of urine and cerebral infarction. Review of Resident #56's Minimum Data Set (MDS) assessment, dated 07/11/18, revealed the resident to have moderate cognitive impairment. Resident #56 was independent with bed mobility and dressing and required supervision with transfers, eating, toileting and personal hygiene. Review of Resident #56's progress note dated 08/16/18 revealed DSS #26 and Unit Coordinator #114 interviewed the resident and the resident denied the allegations of verbal and physical abuse against Resident #98. Resident #56 was offered a room change and she declined. Review of the facility's Self-Reported Incidents (SRIs) revealed no SRI was completed on 08/16/18 when Resident #98 made an allegation of physical and verbal abuse from Resident #56. Interview with the Director of Nursing (DON) on 08/22/18 at 4:22 P.M. verified Resident #98's progress notes revealed the resident made an allegation of physical and verbal abuse against her roommate, Resident #56 on 08/16/18. The DON confirmed no SRIs were completed related to the allegation of abuse on 08/16/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 3 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with DSS #26 on 08/22/18 at 4:35 P.M. verified during a care conference Resident #98 alleged her roommate, Resident #56 hit her and called her names on 08/16/18. Resident #98's POA and Unit Coordinator #114 were present at the time of the allegation. DSS #26 stated the allegation was investigated and unfounded due to there being no injuries, bruising or collaborating statements from other staff and residents. DSS #26 reported Resident #98 was offered a room change and she declined. Resident #98 reported she felt safe in her room and Resident #98's POA also agreed to the resident remaining in the room with Resident #56. DSS #26 reported she did not remember if she told the DON or Administrator about the allegation of physical and verbal abuse on 08/16/18. DDS #26 also reported she was unaware if Unit Coordinator #114 informed the DON or Administrator of the allegation. DDS #26 reported Resident #98 has a history of making allegations against her roommate and there is a care plan for the behavior. Interview with Unit Coordinator #114 on 08/23/18 at 8:51 A.M. revealed DSS #26 asked Unit Coordinator #114 to sit in on a care conference meeting with Resident #98 and her POA on 08/16/18. Unit Coordinator #114 reported Resident #98 alleged Resident #56 had hit her and called her names. Unit Coordinator #114 stated the allegation was investigated and was unfounded. Unit Coordinator #114 stated Resident #98 was offered a room change. Unit Coordinator #114 reported she did not report the allegation of abuse to the Administrator or DON due to Resident #98 having a history of making allegations as a behavior. Review of the facility policy titled Abuse, Neglect and Misappropriation Policy, dated 02/01/17, defines verbal abuse as any use of oral language that willfully includes disparaging or derogatory terms to residents. The policy indicates accurate and timely reporting of incident, both alleged and substantiated, will be sent to officials in accordance with state law. The policy revealed each report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director of the incident or allegation immediately. The policy also reported allegations that do not result in serious bodily injury must be reported to the regulatory bodies within 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 4 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, review of Self-Reported Incidents, and review of facility policy, the facility failed to ensure an allegation of resident to resident physical and verbal abuse was reported to the State Survey Agency. This affected one (#98) of one resident reviewed for abuse. The facility census was 126. Findings include: Review of the medical record revealed Resident #98 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, chronic kidney disease, hypertension, hypothyroidism, mood disorder, major depressive disorder and anemia. Review of Resident #98's Minimum Data Set (MDS) assessment, dated 07/25/18, revealed the resident to have moderate cognitive impairment. Resident #98 required supervision with eating and extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene. Interview on 08/20/18 at 10:44 A.M., Resident #98 reported her roommate, Resident #56, calls her derogatory names daily. Resident #98 also reported Resident #56 hit her and tried to strangle her with the curtains. Resident #98 reported staff were aware of the allegation of physical and verbal abuse. Review of Resident #98's progress note dated 08/16/18 revealed resident alleged her roommate, Resident #56 had hit her and called her names. Director of Social Services (DSS) #26, Unit Coordinator #114, and Resident #98's power of attorney (POA) were present at the time Resident #98 made the allegation of verbal and physical abuse. Further review of the progress note dated 08/16/18 revealed the allegation was investigated and was unfounded. Resident #98 was also offered and declined a room change. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, dementia, chronic pain, hypertension, major depressive disorder, muscle weakness, retention of urine and cerebral infarction. Review of Resident #56's Minimum Data Set (MDS) assessment, dated 07/11/18, revealed the resident to have moderate cognitive impairment. Resident #56 was independent with bed mobility and dressing and required supervision with transfers, eating, toileting and personal hygiene. Review of Resident #56's progress note dated 08/16/18 revealed DSS #26 and Unit Coordinator #114 interviewed the resident and the resident denied the allegations of verbal and physical abuse against Resident #98. Resident #56 was offered a room change and she declined. Review of the facility's Self-Reported Incidents (SRIs) revealed no SRI was completed on 08/16/18 when Resident #98 made an allegation of physical and verbal abuse from Resident #56. Interview with the Director of Nursing (DON) on 08/22/18 at 4:22 P.M. verified Resident #98's progress notes revealed the resident made an allegation of physical and verbal abuse against her roommate, Resident #56 on 08/16/18. The DON confirmed no SRIs were completed related to the allegation of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 5 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0609 abuse on 08/16/18. Level of Harm - Minimal harm or potential for actual harm Interview with DSS #26 on 08/22/18 at 4:35 P.M. verified during a care conference Resident #98 alleged her roommate, Resident #56 hit her and called her names on 08/16/18. Resident #98's POA and Unit Coordinator #114 were present at the time of the allegation. DSS #26 stated the allegation was investigated and unfounded due to there being no injuries, bruising or collaborating statements from other staff and residents. DSS #26 reported Resident #98 was offered a room change and she declined. Resident #98 reported she felt safe in her room and Resident #98's POA also agreed to the resident remaining in the room with Resident #56. DSS #26 reported she did not remember if she told the DON or Administrator about the allegation of physical and verbal abuse on 08/16/18. DDS #26 also reported she was unaware if Unit Coordinator #114 informed the DON or Administrator of the allegation. DDS #26 reported Resident #98 has a history of making allegations against her roommate and there is a care plan for the behavior. Residents Affected - Few Interview with Unit Coordinator #114 on 08/23/18 at 8:51 A.M. revealed DSS #26 asked Unit Coordinator #114 to sit in on a care conference meeting with Resident #98 and her POA on 08/16/18. Unit Coordinator #114 reported Resident #98 alleged Resident #56 had hit her and called her names. Unit Coordinator #114 stated the allegation was investigated and was unfounded. Unit Coordinator #114 stated Resident #98 was offered a room change. Unit Coordinator #114 reported she did not report the allegation of abuse to the Administrator or DON due to Resident #98 having a history of making allegations as a behavior. Review of the facility policy titled Abuse, Neglect and Misappropriation Policy, dated 02/01/17, defines verbal abuse as any use of oral language that willfully includes disparaging or derogatory terms to residents. The policy indicates accurate and timely reporting of incident, both alleged and substantiated, will be sent to officials in accordance with state law. The policy revealed each report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and investigated timely. The supervisor or designee will notify the Director of Nursing and Executive Director of the incident or allegation immediately. The policy also reported allegations that do not result in serious bodily injury must be reported to the regulatory bodies within 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 6 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed notify the state mental health authority with a significant change Pre-admission Screening and Resident Review (PASARR) for a resident with a mental illness that admitted to hospice services. This affected one (#28) of one residents reviewed for significant change PASARR. The facility census was 126. Findings include: Record review revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, schizoaffective disorder, acute kidney failure, chronic pain, hemorrhage of anus and rectum, cardiomyopathy, cerebral infarction, chest pain, brief psychotic disorder, psychosis. The resident was admitted to hospice for congestive heart failure (CHF) on 08/03/18. Review of Resident #28's significant change Minimum Data Set (MDS) assessment, dated 08/10/18, revealed the resident to have moderately impaired cognition. Resident #28 was independent with bed mobility, transfers and required extensive assist with dressing. Resident was also reported to require supervision with eating, toileting, and personal hygiene. The MDS assessment identified the resident was receiving hospice. Review of Resident #28's PASARR dated 04/17/17 revealed resident's initial PASARR was completed at a prior facility. Resident #28's PASARR determination dated 04/20/17 determined him to have serious mental illness with no specialized services. Review of Resident #28's chart did not contain any documentation that a significant change PASARR or notification of significant change was sent to the state mental health authority when the resident was admitted to hospice services on 08/03/18. Review of the handwritten significant change PASARR received on 08/21/18 revealed Business Office Manager (ABOM) #71 signed and dated the PASARR for 08/03/18. The handwritten PASARR did not include any information regarding the PASARR being submitted to the state mental health authority. Interview with Administrator on 08/22/18 at 9:35 A.M. reported the handwritten significant change PASARR completed by ABOM and signed 08/03/18 was completed on 08/21/18 and sent to the state mental health agency on that date. The Administrator verified Resident #28 did not have a significant change PASARR and the board of mental health was not notified of resident's decline and hospice admission on [DATE]. Administrator reported she was not aware of the regulation regarding the state mental health agency being notified of significant changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 7 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to ensure care plans were updated to reflect current treatment needs. This affected two (#89 and #118) of 28 Residents reviewed during the survey. The facility census was 126. Findings include: 1. Medical record review revealed Resident #89 was admitted to the facility on [DATE] with diagnosis of cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/18, revealed the resident had moderately impaired cognitive skills for daily decision making. Resident #89 had functional limitation in range of motion to bilateral upper and lower extremities. A wheelchair was utilized for mobility. Review of physician orders revealed Resident #89 had an order dated 11/22/17 to wear a right hand splint for eight hours, off in the morning and on at night. The order was discontinued on 01/03/18. Review of care plan dated 12/17/14 revealed Resident #89 had alteration in musculoskeletal status related to history of transient ischemic attack (TIA), hypertrophy of bone, Parkinsonism, and stiffness of joint. Current interventions included encourage and assist resident to utilize splint to left hand and elbow as ordered. Observation on 08/20/18 at 3:36 P.M. revealed the resident had a contracture to the right hand without any splint device in place. Interview on 08/23/18 at 3:38 P.M. with the Director of Nursing (DON) reported Resident #89 was placed on restorative services for a right hand splint on 11/30/17 but this was discontinued on 12/29/17 due to non-compliance. The DON verified Resident #89 did not have any splint devices currently ordered. 2. Medical record review revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included other psychoactive substance dependence, herpes viral infection, hypertension, type 2 diabetes mellitus, complication of kidney transplant, bipolar disorder, dysphagia, cerebral infarction, hyperlipidemia, paranoid schizophrenia, and dependence on renal dialysis. Review of Resident #118's quarterly MDS assessment, dated 08/05/18, revealed the resident to be cognitively intact. Resident #118 was found to be independent with bed mobility, transfer, walk in room, toileting and personal hygiene and resident required supervision dressing and eating. Review of Resident #118's physician orders revealed the resident would be changing to Dialysis Center #222 beginning on 04/03/18. Review Resident #118's progress note dated 03/30/2018 revealed resident would be changing to Dialysis Center #222 beginning on 04/03/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 8 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 Review of Resident #118's care plan revealed his dialysis location to be Dialysis Center #221. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #118 on 08/20/18 at 3:32 P.M. revealed the resident attended dialysis at Dialysis Center #222. Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #112 on 08/21/18 at 3:53 P.M. verified Resident #118 received dialysis at Dialysis Center #222. Interview with Administrator on 08/22/18 at 9:35 A.M. verified Resident #118's care plan listed Dialysis Center #221 instead of his current provider of Dialysis Center #222. The Administrator reported the resident changed dialysis facilities on 04/2018. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 9 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and review of facility policy, the facility failed to ensure an assessment was completed for risk of entrapment prior to the use of side rails. This affected one (#110) of five residents reviewed for accidents. The facility census was 126. Findings include: Review of the medical record revealed Resident #110 was admitted to the facility on [DATE] with a re-entry date of 04/26/18. Diagnoses included paraplegia, cerebral infarction, and obesity. Review of 14 day Minimum Data Set (MDS) assessment, dated 08/07/18, revealed the resident had moderately impaired cognitive skills for daily decision making. The resident required extensive assistance from staff for bed mobility, toileting, and personal hygiene. Resident #110 was dependent upon staff for transfers. A wheelchair was utilized for mobility. Review of bed safety review assessments, dated 03/23/18 and 04/26/18, revealed Resident #110 had a trapeze bar, and a half side rail to one side of the bed with the bed against the wall on one side. The assessment instructed to measure the distance between the headboard and the top of the mattress (no greater then 2.5 inches) with the findings left blank on both assessments. The assessment also instructed to measure the distance between the side of the mattress and the side rail where the rail and headboard do not meet (not to be greater than 4.5 inches), which was also left blank on both assessments. The assessment instructed staff to stop use if gaps were identified that exceeded the guidelines or if mattress slides on the frame. Observation on 08/21/18 at 9:00 A.M. revealed Resident #110 was on a bariatric low air loss (LAL) mattress with bilateral upper side rails. Gaps were observed between the left side rail and mattress and the top of the mattress and head board. Interview on 08/21/18 at 9:00 A.M. at the time of the observation, Resident #110 reported the bed frame was too big for the mattress, but that was all the facility had to accommodate the bariatric LAL mattress. Resident #110 stated he/she was able to utilize the side rails to position his/her upper body. Observation on 08/22/18 at 12:00 P.M. with Maintenance Director (MD) #67 obtained measurements which revealed the gap between the left side rail and mattress was 4.25 inches and the gap between the mattress and headboard was 5.50 inches. MD #67 reported the headboard was able to be adjusted which would decrease the gap to three inches. Interview on 08/23/18 at 5:47 P.M. with the Director of Nursing (DON) reported the side rail assessment was not completed and gaps were not measured to assess risks of entrapment for Resident #110 prior to use of side rails. Review of facility policy titled Side Rail Assessment and Consent Policy, revised 04/23/18, revealed a side rail assessment would be completed for use of side rails. In the event a gap between the mattress/bed and the side rail was greater than 2.5 inches, then gap stops were required to be in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 10 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 0700 place. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 11 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 facility policy review, the facility failed to ensure sanitizer buckets contained appropriate levels of sanitizer and failed to maintain the refrigerator and second floor tray drinks in a manner to prevent and protect food against contamination and spoilage. This affected all 125 residents receiving food from the kitchen. Resident #43 received nothing by mouth. The facility census was 126. Findings include: 1. Observation of the kitchen on 08/20/18 at 9:13 A.M. revealed one sanitizer bucket to be in use in the kitchen. Observation of Dietary Manager (DM) #136 testing the sanitizer bucket revealed the sanitizer level to be at 0 parts per million (ppm). DM #136 emptied the bucket of sanitizer and refilled the bucket. Observation of DM #136 testing the refilled sanitizer bucket revealed the sanitizer level to be at 0 ppm. Interview with DM #136 on 08/20/18 at 9:13 A.M. verified the finding of the sanitizer bucket testing at 0 ppm. Review of the facility policy titled Equipment, dated May 2014, revealed the Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use. 2. Observation on 08/21/18 at 8:00 A.M. of the refrigerator in the dining room on the first floor on 08/21/18 at 8:00 A.M. revealed an open undated two liter of cola with an expiration date of 07/23/18. Interview with Nursing Staff Scheduler #63 on 08/21/18 at 8:00 A.M. verified the finding of an open undated two liter of cola with an expiration date of 07/23/18. 3. Observation of the second floor tray cart on 08/23/18 at 12:54 P.M. revealed the cart to be metal and open to air. The cart contained trays with uncovered juices on them. Interview with Dietary General Manager #135 on 08/23/18 at 12:54 P.M. verified the second floor tray cart was open to air and contain trays with uncovered juices. Review of the list of room trays on the second floor revealed nine residents (#54, #7, #8, #324, #112, #36, #66, #5, and #107) to receive meal trays in their rooms on the second floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 12 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 record review, staff interview, and review of facility policy, the facility failed to ensure the code status was accurately documented in the medical record for one (#41) of 32 residents reviewed for accurate advanced directives. The facility census was 126. Findings include: Record review revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder, anxiety disorder, mild cognitive impairment, gastro-esophageal reflux disease, Crohn's disease, dementia with Lewy bodies, hypertension, chronic obstructive pulmonary disease, and glaucoma. Review of the quarterly Minimum Data Sets (MDSs) assessment, dated 07/08/18, revealed Resident #41 had mild cognitive impairment. Review of Resident #41's non-electronic chart revealed an advanced directive tab with a sticker indicating Resident #41 to be a full code. Further review of the non-electronic chart revealed Resident #41 had a code status form indicating his code status to be Do Not Resuscitate Comfort Care (DNRCC). This form was located behind the advanced directives tab. Resident #41 and Physician #134 signed and dated the form on 11/15/17. Review of Resident #41's code status in his electronic record revealed resident's code status to be listed as a DNRCC. Review of Resident #41's care plan revealed resident to be listed as a DNRCC in his care plan. Interview with Licensed Practical Nurse (LPN) #122 on 08/20/18 at 2:44 P.M. verified the finding of Resident #41's non-electronic chart containing a tab with a sticker indicating resident's code status to be a full code. LPN #122 also confirmed Resident #41's non-electronic chart contained a signed code status form indicating resident's code status to be a DNRCC. LPN #122 reported the sticker on the advanced directives tab should have listed resident's code status as a DNRCC. Review of the facility policy titled General Code Status, dated 05/11/18, revealed the facility should maintain an efficient and accurate method of determining the code status of a resident during a medical emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 13 of 14 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 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of pest control service records, and staff interview, the facility failed to maintain windows in a manner to prevent the entrance of an excessive number of flies. This affected three rooms (#109, #303, and #224) and the second floor dining room. This had the potential to affect all 126 resident residing in the facility. Residents Affected - Some Findings include: Observation on 08/20/18 at 10:21 A.M. of room [ROOM NUMBER] revealed approximately five flies to be on a napkin on the bedside table. There was a denture case covered with a plastic food container lid. The food lid was not fitted to the denture case. The resident in the room removed the plastic food lid from the top of the denture case during the observation and multiple flies came out of the denture case. There was also a urinal on a walker with three flies sitting on the urinal. Interview on 08/20/18 at 10:21 A.M., Licensed Practical Nurse (LPN) #122 verified the excessive number of flies present in room [ROOM NUMBER]. Observation on 08/21/18 at 4:42 P.M. in room [ROOM NUMBER] revealed two flies to be in the room. Interview on 08/21/18 at 4:42 P.M., LPN #91 verified the observation of the flies in room [ROOM NUMBER]. Observation on 08/23/18 at 1:43 P.M. of room [ROOM NUMBER] revealed the window to be cracked open approximately two inches without a screen in place. Flies were observed throughout the room. Observation of the second floor dining room on 08/23/18 at 1:04 P.M. revealed multiple flies present while residents were eating lunch. Interview with Licensed Practical Nurse (LPN) #44 verified none of the windows on the secured second floor have screens. LPN #44 revealed residents on this unit do open their windows, but not very far. Review of pest control service records dated 07/26/18 revealed the facility had flies present. room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were sprayed for flies. Review of pest control service records dated 08/20/18 revealed the facility continued to have flies present. The second floor and room [ROOM NUMBER] were treated for flies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 14 of 14