Inspection·September 19, 2019

F 0641 the ground. The transport company call 911 and resident was sent to the emergency room. Level of Harm - Minimal harm or potential for actual harm Review of Resident #84's emergency department notes dated 08/05/19 revealed emergency medical services were notified of possible seizure like activity. Resident #84 passed out and fell to the floor but was caught by the nursing staff. Residents Affected - Few Review of Resident #84's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively intact and required supervision for bed mobility, dressing and eating. Resident #84 also required limited assistance with transfer and toileting and was independent with personal hygiene. Interview with the Director of Nursing (DON) on 09/18/19 at 11:37 A.M. verified Resident #84's fall was not coded on the 08/05/19 MDS. Review of the Resident Assessment Instrument (RAI) manual dated October 2019 revealed Review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home. Include medical records generated in any health care setting since last assessment. All relevant records received from acute and post-acute facilities where the resident was admitted during the look-back period should be reviewed for evidence of one or more falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 2 of 9 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 09/19/2019 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to accurately complete pre-admission screening and resident review (PASARR) for a newly admitted resident. This affected one (Resident #57) of four residents reviewed for PASARR. The facility census was 137. Residents Affected - Few Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] from the hospital with the following diagnoses; localized edema, schizoaffective disorder, type two diabetes mellitus without complications, hyperlipidemia, essential hypertension, chronic pain, acquired absence of left and above knee, other schizophrenia, other fatigue, chronic kidney disease and cognitive communication deficit. Review of Resident #57's PASARR dated 04/19/19 revealed resident to have mood disorder. Resident #57's diagnosis of other schizophrenia was not marked and the indication of serious mental illness was not identified on the PASARR. Interview with the Director of Nursing (DON) and the Administrator on 09/18/19 at 11:37 A.M. verified Resident #57's diagnosis of schizophrenia was not identified and was incorrectly reported to have a diagnosis of mood disorder on the PASARR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 3 of 9 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 09/19/2019 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review, observation, staff interview and policy review, the facility failed to discard expired medications and failed to label multi dose medication with the expiration date. This affected one medication room and one medication cart. The census was 137. Findings include: 1. Observation on 09/17/19 at 10:08 A.M. with LPN #117 of the medication storage room on the first floor revealed nine single dose vials of influenza vaccine with an expiration date of 04/09/19. Interview with LPN #117 on 09/17/19 at 10:08 A.M. confirmed that the expired influenza vaccine should have been discarded. Interview on 09/17/19 at 12:53 P.M. with the DON confirmed that influenza vaccine should be discarded when expired. Review of the policy titled Resident Influenza Vaccine, undated, revealed that influenza season is October 1 through March 31 and that residents residing in the facility just prior to the onset of influenza season would be offered the influenza vaccine, unless medically contraindicated. 2. Observation on 09/17/19 at 10:08 A.M. with LPN #117 of the medication storage room on the first floor revealed two open and undated multi-dose vials of injectable tuberculosis testing solution. Interview with LPN #117 on 09/17/19 at 10:08 A.M. confirmed that the bottles of TB solution were not dated but should be dated once the vial is opened and discarded in 30 days and that as the vials were not dated, she was unsure if the testing solution was expired. Review of manufacturer's recommendations for the tuberculosis testing solution revealed that once a multi-dose vial was opened, it should be discarded within 30 days. 3. Observation of medication storage on 09/17/19 at 10:38 A.M. with LPN #36 revealed a package containing twelve hydrocortisone acetate suppositories with an expiration date of 05/31/19. Interview with LPN #36 on 09/17/19 at 10:38 A.M. confirmed the suppositories were expired and should have been discarded. 4. Observation of third floor west medication cart on 09/17/19 at 10:52 A.M. with LPN #99 revealed a house stock bottle of sodium bicarbonate antacid with an expiration date of 07/2019. Interview on 09/17/19 at 10:52 A.M. with LPN #99 confirmed the expired sodium bicarbonate was expired and should have been discarded. 5. Observation of third floor west medication cart on 09/17/19 at 10:52 A.M. with LPN #99 revealed open and undated bottles of eye drops for the following residents: latanaprost eye and Systane eye for Resident #125, olopatadine for Resident #25, prednisolone acetate for Resident #7, latanaprost for Resident #390. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 4 of 9 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 09/19/2019 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 09/17/19 at 10:52 A.M. with LPN #99 confirmed that the opened bottles of eye drops for Residents #125, #25, #7 and #390 should have been dated when opened and discarded in 28 days. Review of policy titled Medication Administration, dated 05/29/10, revealed that multi-dose containers of medications that expire after opening should be labeled with the date opened and expired medications should be discarded. Review of policy titled Storage of Medications revealed certain medications such as opthalmics (eye meds) and multi dose injectable vials require an expiration date shorter than the manufacturer's expiration date and should be dated when the original seal of a container opened, that no expired medication shall be administered to a resident, and that all expired meds will be removed from active supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 5 of 9 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 09/19/2019 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** 2. Resident # 51 was admitted to the facility in July 2016 and had current diagnoses including schizoaffective disorder bipolar type, dementia with behavioral disturbance, hypertension, convulsions, epilepsy, borderline personality disorder, osteoarthritis, morbid obesity, heart failure, and mood disorder. On 07/16/19 the diagnoses of displace bimalleolar fracture of right lower leg was added. The facility completed a quarterly minimum data set (MDS) assessment on 07/23/19. The assessment identified the resident as having good memory and recall along with delusions, intermittent inattention, and disorganized thinking. The resident required the physical assistance of one staff to complete all activities of daily living other than eating. Resident #51 was observed on 09/17/19 at 11:56 A.M. wheeling himself about the second floor dining/activity room. He was wearing a orthopedic boot to his right ankle and foot. Review of Resident #51's nursing progress notes revealed an entry by Licensed Practical Nurse (LPN) #49 on 06/17/19 at 4:05 P.M. documenting the resident was complaining of right ankle pain, full range of motion was noted, there was no bruising or redness. The nurse noted that she made the resident's physician and representative aware, and a new order was received to obtain an x-ray of the resident's right ankle. On 06/18/19, LPN #49 documented that x-ray results were received, the resident's physician was made aware. The conclusion was a possible recent non-displaced fracture of the distal fibula. LPN #49 noted that a new order was received to obtain oblique views per suggestion of the previous results, the resident was to be non-weight bearing to the right lower extremity, and to refer the resident to an orthopedic physician. The nurse noted the resident's representative was made aware of the the new orders. On 06/18/19 Unit Manager, LPN #36 documented in Resident #51's nursing progress notes that the Nurse Practitioner gave an order to send the resident to the emergency room due to non-compliance with non-weight bearing status, and refusal to use a wheelchair. The resident's representative was made aware. On 06/18/19 at 10:00 P.M., LPN #61 documented in Resident #51's nursing progress notes the resident returned to the facility at 9:33 P.M. She noted the resident had a soft cast to his right ankle and has been instructed not to bear weight to his right extremity. Resident #51's x-ray of his right leg/ankle dated 06/18/19 were reviewed. The radiologist documented on 06/18/19 the resident had a non-displaced fracture of the right distal fibula. A fall investigation for the fall which Resident #51 sustained which resulted in the ankle fracture was requested from the Director of Nursing (DON) as it was not evident in the nursing progress notes when the fall occurred. Review of the occurrence report indicated that Resident #51 originally fell on [DATE] at 7:05 P.M. The occurrence report/fall details report specified that State Tested Nurse Aide (STNA) #37 found the resident on the floor in his room sitting in urine. Further review revealed the fall was investigated by Unit Manager, LPN #36 on 06/17/19. LPN #36 noted on 06/17/19 that the resident's physician and responsible party was notified about the fall on 06/17/19 at 3:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 6 of 9 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 09/19/2019 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 The nurse noted the resident was found on the floor in his room, sitting in urine, and denied any pain. He was able to perform range of motion as usual, and was refusing to get off the floor. After several minutes the resident began to comply, but refused to go to the bathroom. LPN #36 noted an STNA cleaned and changed him while he was in bed, and the resident was encouraged to use the call light to transfer and to toilet. Residents Affected - Few Resident #51's nursing progress notes, and occurrence reports/fall details report dated 06/17/19 were reviewed with LPN #36 on 09/19/19 at 10:34 A.M. LPN #36 was interviewed regarding no notation of the resident ever having a fall on 06/16/19 in the nursing progress notes. LPN #36 confirmed there was no nursing progress note describing the fall that occurred on 06/16/19, including circumstances surrounding the fall, what was occurring at the time of the fall, where the fall occurred, or nursing assessment for any injury. In addition, there was no documentation of any physician or representative notification. LPN #36 reported the fall did occur on 06/16/19 which was on a Sunday, and the first mention of the fall was during the 06/17/19 nursing progress note by LPN #49 when the resident complained of right ankle pain. Based on record review and interview, the facility failed to ensure a resident's code status was accurately documented in the electronic record and a resident's fall with nursing assessment was documented in the medical record. This affected two (Resident #51 and Resident #61) of 33 residents reviewed for complete and accurate medical records. The resident census was 137. Findings include: 1. Record review revealed Resident #61 was admitted to the facility on [DATE]. Review of Resident #61's code status in the electronic chart on 09/09/19 revealed resident to be listed as a Do Not Resuscitate Comfort Care (DNRCC). Review of Resident #61's code status in the paper chart revealed resident to have a code status form indicating resident was a Do Not Resuscitate Comfort Care Arrest (DNRCCA) that was signed by the physician on 05/17/18. Interview with the Director of Nursing (DON) and the Administrator on 09/18/19 at 11:37 A.M. verified Resident #61's DNRCC code status in the electronic chart did not match her DNRCCA code status listed in the paper chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 7 of 9 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 09/19/2019 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of facility policy, the facility failed to perform hand hygiene between resident medication administrations and failed to follow infection control principles while preparing medications. This had the potential to affect four (Resident #72, #80, #127, #131) of seven residents observed for medication administration. The facility also failed to implement proper infection control measures for a central intravenous (IV) line for one (Resident #75) of two residents reviewed for dialysis. The census was 137. Residents Affected - Few Findings include: Observation of Licensed Practical Nurse (LPN) #99 on 09/18/19 at 8:45 A.M. administering medications to Resident #80 revealed nurse touched five medications with her bare hands after touching the keys to the cart and the computer. LPN #99 then dispensed a vitamin D tablet out of house stock medication bottle into cup containing Resident #80's medications. LPN #99 removed the vitamin D tablet from the cup with her bare hands, touching the other medications for Resident #80 and the placed the vitamin D tablet back into the house stock bottle. LPN #99 then dispensed a vitamin B12 tablet into the medicine cup and administered the entire cup of medications to the resident. Observation of LPN #99 administering medications to Resident #131 on 09/18/19 at 8:52 A.M. revealed the nurse touched two medications with her bare hands after touching the keys to the cart and the computer. LPN #99 then administered the meds to the resident. Observation of medication administration to Resident #127 per LPN #99 on 09/18/19 at 8:58 A.M. revealed nurse did not perform hand hygiene after administering Resident #131's medications and that nurse touched the five medications for Resident #127 with her bare hands after touching keys to the cart and the computer. LPN #99 then administered the meds to the resident. Observation of medication administration to Resident #72 per Licensed Practical Nurse (LPN) #99 on 09/18/19 at 9:05 A.M. revealed the nurse did not perform hand hygiene after administering Resident #127's medications and that the nurse touched four medications for Resident #72 after touching keys to the cart and the computer. Interview with LPN #99 on 09/18/19 at 8:45 A.M. confirmed that she accidentally prepared a vitamin D tablet for administration to Resident #80 and when she realized that the resident's order was for vitamin B-12 and not vitamin D, she removed the vitamin D tablet from the resident's medication cup and placed it back in the house stock bottle of vitamin D tablets. LPN #99 confirmed that she touched Resident #80's medications with her bare hands, popping the pills out of medication cards into her hands and then dropping the pills into a medication cup. LPN #99 confirmed that she felt it was acceptable to touch the pills with her bare hands and return the vitamin D tablet she had touched with her bare hands back to the house stock bottle because she had washed her hands with soap and water before starting her medication pass. Interview with LPN #99 on 09/18/19 at 9:10 A.M. confirmed that nurse had not washed or sanitized her hands prior to medication administration to Residents #131, #127, and #72 and that she had touched these residents' medications with her bare unwashed hands prior to administration. Review of facility policy titled Medication Administration, dated 05/29/19, revealed nurses should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 8 of 9 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 09/19/2019 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not touch residents' medications with their bare hands and that nurses should perform hand hygiene before and after each resident medication administration. 2. Review of the medical record for Resident # 75 revealed an admission date of 06/25/13 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes mellitus type two, chronic kidney disease stage three and hypertension. His quarterly Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented. Observation on 09/16/19 at 3:30 P.M. revealed Resident #75's central venous catheter line dressing located on his right upper chest was unsecured and open to air. There was no date on the dressing and there multiple flies flying around the unsecured dressing area. Interview on 09/16/19 at 3:35 P.M. with Resident #75 revealed he was no longer going to dialysis. He could not recall the exact date when his dialysis stopped. He stated he could not recall anyone looking at the dressing. Interview on 09/16/19 at 3:41 P.M. with the Director of Nursing (DON) confirmed the dressing was unsecured and flies were flying around the dressing. Interview on 09/19/19 at 8:48 A.M. with dialysis center RN revealed the facility was not to change the dressing. She stated they were to monitor it and reinforce the dressing. Review of the Medication Administration Records and the Treatment Administration Records for September 2019 revealed there was no documentation the facility had been monitoring the site of the central venous catheter. Review of the facility policy titled Hemodialysis Care and Monitoring, dated 03/23/18, revealed under the section titled, General Vascular Access Device, the nurse will be aware of the specific type of vascular access device the resident has, for assessment and monitoring purposes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 9 of 9