Inspection·November 30, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure a resident's advanced directives were accurately reflected in the clinical record. This affected one (#127) of the 32 residents reviewed for advanced directives. The facility census was 137. Findings included: Review of the medical record for Resident #127 revealed the resident was admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, protein-calorie malnutrition, fracture of the upper end of the right humerus, tobacco use, seizures, functional urinary incontinence, cerebral infarction, occlusion and stenosis of the left carotid artery, dysphagia following cerebral infarction, hypertension, and facial weakness following cerebral infarction. Review of the paper chart for Resident #127 revealed the resident had a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated [DATE]. Review of the electronic medical record (EMR) on [DATE] at 12:20 P.M. revealed the resident had an order for cardiopulmonary resuscitation (CPR). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #127, revealed a Brief Interview for Mental Status (BIMS) score of four indicating she had severe cognitive impairment. Review of the care plan for Resident #127 revealed the resident had a CPR code status. One of the interventions included obtaining a medical provider order for a code status. Interview with Registered Nurse Unit (RN) Manager #80 on [DATE] at 10:30 A.M. verified Resident #127's orders did not match the signed advanced directives. Review of the undated facility policy titled Advance Directive (Resident's Right to Choose) revealed any decision making regarding the resident's choice in their medical order for life-sustaining treatment and/or their advanced directive will be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 2 of 13 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 11/30/2023 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, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed correctly to include a mental health diagnosis. This affected one (#74) of five residents reviewed for PASARR. The facility census was 137. Residents Affected - Few Findings include: Review of the medical record for Resident #74 revealed the resident was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, type two diabetes mellitus without complications, hypertensive heart and chronic kidney disease with heart failure, venous insufficiency, and anemia. Review of the history and physical dated 05/06/22 revealed Resident #74 had a diagnosis of schizophrenia. Review of the PASARR dated 05/09/22 indicated Resident #74 had no indications of serious mental illness, such as schizophrenia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #74 revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Interview on 11/30/23 at 11:09 A.M. with Assistant Business Office Manager (ABOM) #13 verified Resident #74 had a diagnosis of schizophrenia in the electronic health record that she was unaware of, which had not been marked on the PASARR completed on 05/09/22. Review of the facility policy titled PASARR - Pre-admission Screening and Resident Review, reviewed 08/11/20, revealed all individuals that applied for admission to a Medicaid certified nursing facility must be screened for a PASARR disability whether they have such a disability and, if so, whether they need specialized services to address their PASARR related needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 3 of 13 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 11/30/2023 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 record review and staff interview the facility failed to ensure care conferences were completed. This affected two (#117 and #29) of the 27 residents reviewed for care planning. The facility census was 137. Findings include: 1) Review of the medical record for Resident #117 revealed the resident was admitted on [DATE]. Diagnoses included schizophrenia, anxiety, hallucinations, and depression. Review of the medical record from 08/26/22 through 11/30/23 for Resident #117 revealed no documented evidence of a care conference being completed. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #117. Revealed the resident had no cognitive impairments and was independent with activities of daily living (ADLs). Interview with Resident #117 on 11/27/23 at 3:18 P.M. revealed the resident had never been provided with a care conference. Interview Social Service Designee (SSD) #111 on 11/30/23 at 12:48 P.M. verified Resident #117 was admitted on [DATE] and the resident had never had a care conference. 2) Review of the medical record for Resident #29 revealed the resident was admitted on [DATE]. Diagnoses included schizoaffective disorder, type two diabetes, spinal stenosis, chronic obstructive pulmonary disease (COPD) and schizoaffective disorder. Review of the medical record for Resident #29 from 01/01/22 through 11/30/23 revealed Resident #29 had no documented evidence of any care conferences being completed. Review of the MDS assessment dated [DATE] for Resident #29 revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Review of the plan of care dated 10/23/23 revealed Resident #29 was at risk for nutritional decline related to type two diabetes, hypertension, hyperlipidemia, COPD, major depressive disorder, anxiety disorder, obesity, anemia, schizoaffective disorder; therapeutic diet; edema, history significant weight loss (planned/favorable) with weight cycling and history of wounds. Interview with Resident #29 on 11/28/23 at 12:29 P.M. revealed the resident did not have any care conferences. Interview with SSD #111 on 11/30/23 at 12:55 P.M. verified Resident #29 had no documented evidence of any care conferences being completed. Interview with the Administrator on 11/30/23 at 2:14 P.M. verified Resident #29 had no care documented care conferences in 2022 or 2023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 4 of 13 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 11/30/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, medical record review and review of facility policy, the facility failed to ensure dependent residents were provided with effective grooming. This affected one (#86) of the four residents reviewed for the provision of activities of daily living (ADLs). The facility census was 137. Residents Affected - Few Findings Included: Review of medical record for Resident #86 revealed an admission date 07/26/23. Diagnoses included chronic obstructive pulmonary disease (COPD), bipolar disorder, and malignant neoplasm of upper lobe left, secondary malignant neoplasm of brain. Review of the plan of care dated 07/28/23 revealed that Resident #86 had an ADLs self-care performance deficit related to signs and symptoms of involving musculoskeletal system, chronic pulmonary disease, migraines, fatigue, unsteadiness on feet, and poor motivation towards self-care. Interventions included staff to provide all assistance with showers/grooming. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #86 revealed the resident had a Brief Interview of Mental Status (BIMS) of 11 which indicated the resident was cognitively impaired. Resident #86 was dependent for showers /bathing and personal hygiene. Observation and interview with Resident #86 on 11/28/23 at 10:00 A.M. revealed the resident who was lying in bed with a facility gown on and had numerous dark facial hairs on her chin which were approximately one and a half inches in length. Resident #86 stated it had been a while since her chin hair had been addressed. Observation of Resident #86 on 11/29/23 at 1:30 P.M. with Certified Nurse Aid (CNA) #28 verified Resident #86 had chin hair and stated the resident was not bothered by it. Observation of Resident #86 on 11/30/23 at 11:00 A.M. revealed the resident was lying in her room in bed and her facial hair was still present. Interview with Resident #86 on 11/30/23 at 11:30 A.M. along with Licensed Practical Nurse (LPN) #95 who asked Resident #86 if she wanted her facial hair on her chin plucked with tweezers. Resident #86 reported she wanted her chin hair plucked out. LPN #95 stated she was not able to find any tweezers, so she would offer to shave resident's chin hair. Resident #86 stated she would like her chin hair removed. Review of facility policy undated titled Routine Resident Care revealed the facility would promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs, and honor resident lifestyle preferences while in the care of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 5 of 13 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 11/30/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A chart review revealed Resident #187 was admitted on [DATE]. Diagnoses included mood disorder, brain cancer, insomnia, suicidal behaviors, depression, bilateral below the knee amputation, and anxiety. Review of MDS assessment dated [DATE] revealed Resident #187 had mild cognitive impairment and required limited to moderate assistance with ADLs. Review of care plan dated 11/10/23 revealed Resident #187 utilized nicotine products with an intervention dated 11/10/23 to complete a smoking evaluation. Review of medical record for Resident #187, revealed no documented evidence of a smoking assessment being completed. An interview on 11/27/23 at 4:54 P.M. with Resident #187 stated that the facility told him he would be able to smoke whenever he wanted, and after he was admitted they changed the rules and he had to wait for smoke times. An interview on 11/30/23 at 10:33 A.M. with the Director of Nursing verified Resident #187 had no smoking evaluation completed. Review of Resident Smoking Policy (dated 05/30/19) revealed assessment, observation, and designation of independent or supervised smoker will be made by the interdisciplinary team for each resident who requests to smoke in the facility with the screening in the electronic medical record system. Based on record review, staff interviews, and review of facility policies, the facility failed to ensure a fall was thoroughly investigated, accurately documented, and fall interventions were implemented to prevent additional falls. This affected one (#04) of the nine residents reviewed for accident hazards. The facility also failed to ensure residents were supervised while smoking, failed to ensure residents smoked safely and failed to ensure residents were assessed for smoking. This affected four (#10, #95, #04, and #187) of the nine residents reviewed for accident hazards. The facility census was 137. Findings include: 1) Review of the medical record for Resident #04 revealed he was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure, vascular dementia moderate with other behavioral disturbance, other intervertebral disc degeneration, peripheral vascular disease, unspecified protein-calorie malnutrition, personality disorder, mixed hyperlipidemia, polyosteoarthritis, paranoid schizophrenia, vitamin d deficiency, and aphasia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #04 revealed the resident had significantly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 06. This resident was assessed to require extensive assistance of two for activities of daily living (ADLs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 6 of 13 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 11/30/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Review of the plan of care revised on 09/21/22 revealed Resident #04 was at risk for falls related to impaired judgement and safety awareness, gait problems, impaired mobility, weakness, frequently attempted self-transfer, and resistive to fall interventions. Interventions included for the bed to be in the lowest position, the room free of accident hazards, resident to wear non-skid footwear, the call light within reach, and review the past falls and implement interventions as ordered. Residents Affected - Some Review of the nurse's progress note dated 01/29/23 at 6:00 P.M. and recorded as a late entry, revealed Resident #04 was observed sitting in the hallway in front of his wheelchair in an upright position from an unwitnessed fall. The resident was assessed to have increased confusion and decreased oxygen saturation. Resident #04 stated he was picking up a soda bottle that he dropped when he fell. Resident #04 reported no pain, and the resident was assisted back in wheelchair with assistance of two staff members. Oxygen was applied to the resident and new orders were received to obtain a chest X-ray, laboratory (labs) tests and neurological (neuro) checks were started. The nurse's progress note revealed no documented evidence of any fall interventions being implemented. Review of a post fall evaluation/notification dated 01/29/23 at 6:00 P.M. for Resident #04, revealed the resident had unwitnessed fall and had no injuries or pain as result of fall. The post fall evaluation/notification revealed no documented evidence of any fall interventions being implemented. Review of the Situation Background Assessment Recommendation (SBAR) electronic interaction (eINTERACT) summary for providers dated 01/29/23 at 6:00 P.M. for Resident #04, revealed the resident had a change in condition related to falls. The SBAR revealed no documented evidence of any fall interventions being implemented. Review of a facility incident report indicated on 01/29/23 at 6:00 P.M. Resident #04 had an unwitnessed fall and was found in the hallway sitting on his buttocks in front of his wheelchair. Resident #04 stated he was trying to pick up a pop bottle. Resident #04 was assessed with no pain with range of motion assessment. The resident was placed back in his wheelchair. The resident was noted to be more confused with a decreased oxygen saturation level. The incident report revealed no documented evidence of any fall interventions being implemented. Review of the physician's progress note dated 01/30/23 at 8:18 A.M for Resident #04, revealed the resident complained of shortness of breath over weekend and a chest x-ray and labs were ordered. The resident's x-ray showed pneumonia. The physician's progress noted revealed no documentation about the resident's fall on 01/29/23. Review of the Interdisciplinary Team (IDT) progress note dated 02/01/23 at 8:50 A.M. for Resident #04 revealed the resident had a fall with no injury from leaning forward in his chair. The Root cause of the incident indicated the resident had an altered mental status and confusion. Interventions put in place were chest x-ray and labs. The IDT Team progress note revealed no documented evidence that the facility implemented any fall interventions for Resident #04. Review of the physician's progress note dated 02/01/23 at 11:31 A.M. for Resident #04 revealed the resident had a follow up for pneumonia. The physician's progress note revealed no documentation about the resident's fall on 01/29/23. Review of the nurse's progress notes from 02/01/23 through 02/09/23 revealed no documented evidence of Resident #04 falling or other related incidents related to an injury. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 7 of 13 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 11/30/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a facility incident report dated 02/09/23 and authored by Director of Nursing (DON) revealed Resident #04 had an unwitnessed fall in the resident's room on 02/09/23 at 6:15 P.M. The resident was found sitting on the floor in his room. The resident was assessed to have left hip pain when range of motion assessment was performed. Resident #04 was placed back in bed and a skin grid sheet was initiated. The follow up note entered by the DON on 02/16/23 at 3:18 P.M. revealed when STNA was performing incontinence care (on 02/10/23), the resident was screaming in pain. The nurse noted an abnormal appearance and bruising. 911 was called and a resident was sent to the hospital for evaluation. Review of the SBAR eINTERACT form dated 02/10/23 at 3:44 P.M. for Resident #04, revealed the resident had uncontrolled pain and a skin wound on right front thigh related to a fall and resident was sent to the ER. Review of the nurse's progress note dated 02/10/23 at 3:52 P.M. for Resident #04, revealed a STNA informed the nurse that Resident #04 was screaming out in pain during incontinence care. The nurse assessed Resident #04 and noted Resident #04's left hip appeared abnormal and had bruising to right lower extremity. Resident #04 reported pain level was a 10 out of 10 (scale of pain where zero is no pain and 10 is extreme pain), and emergency services were called to transport Resident #04 to the hospital for evaluation. Review of a facility incident report dated 02/10/23 at 3:25 P.M. revealed an unusual occurrence in the resident room. Resident #04 was assessed with increased pain and bruising to right inner thigh and decreased range of motion to the right lower extremity and the resident was sent to the hospital. Resident #04 was noted with fall on 01/29/23. Resident #04 was diagnosed with an acute displaced intertrochanteric fracture proximal left femur. The Incident report did not mention the resident's fall on 02/09/23 at 6:00 P.M. Review of the IDT progress note dated 02/10/23 at 5:42 P.M. and recorded as a late entry, revealed Resident #04 had bruising, pain, and decreased range of motion while receiving peri-care and refused to allow peri-care due to the pain. The nurse assessed resident legs to have bruising. The root cause of incident was noted to be a fall on 01/29/23 with injury and resident had a delayed response to feeling pain and reported pain due to medication received to suppress injury (prednisone [steroid]). Interventions revealed resident was sent to hospital for evaluation and treatment. There is no mention of the resident's fall on 02/09/23. Review of the nurse's progress note dated 02/11/23 revealed Resident #04 had a left hip fracture and would be having surgery on 02/12/23. Interview with the with the Director of Nursing (DON) on 11/29/23 at 1:18 P.M. confirmed Resident #04 had a fall on 01/29/23 and the facility implement interventions for a chest x-ray and labs to be completed. The DON also confirmed the resident had another fall on 02/09/23 when an agency nurse was on duty. The DON stated he advised the agency nurse to complete her investigation on paper because of the limited access to their risk management in the electronic health record. A follow-up interview with the DON on 11/29/23 at 3:21 P.M. confirmed there was no documentation related to Resident #04's fall on 02/09/23 in the resident electronic health record. The DON also verified the incident report completed on 02/09/23 lacked a thorough summary of the incident. The DON acknowledged the IDT follow-up on 02/10/23 failed to address the resident's fall on 02/09/23. The DON also verified there were no fall interventions placed for resident after the resident fell on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 8 of 13 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 11/30/2023 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 0689 and again on 02/09/23. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Fall Prevention and Management, revised 06/01/22, revealed the interdisciplinary team should review information for all falls at the next Daily Clinical Meeting. The team should discuss the fall, potential causes, interventions, and a deep root cause investigation should be discussed. A progress note of the discussion should be placed in the resident's chart. Residents Affected - Some 2) Review of the medical record for Resident #10 revealed he was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder bipolar type, type two diabetes mellitus without complications, cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery, vascular dementia moderate with other behavioral disturbance, bipolar disorder, peripheral vascular disease, major depressive disorder, generalized anxiety disorder, and delusional disorders, Review of the quarterly MDS assessment dated [DATE] for Resident #10, revealed the resident had intact cognition evidenced by a BIMS score of 13. This resident was assessed to require extensive assistance for ADLs. Review of the plan of care revised on 06/12/23 revealed Resident #10 utilized nicotine products and had a history of non-compliance with the smoking policy. Interventions included complete smoking evaluation, educating resident/resident representative on smoking policy, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #10 required supervision while smoking. Observation on 11/28/23 at 11:08 A.M. of Resident #10 revealed he was outside the facility entrance smoking with no staff present. Interview at the time of the observation with Nursing Staff Scheduler #149 confirmed Resident #10 was smoking outside the facility entrance by himself and not in the designated smoking area. Nursing Staff Scheduler #149 reported the aide that was supervising the smoke area had gone to the bathroom. Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, vascular dementia, psychotic disturbance, mood disturbance, and anxiety, hypertension, cardiomyopathy, and insomnia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #95 had severely impaired cognition evidenced by a BIMS score of 06. This resident was assessed to require supervision for ADLs. Review of the plan of care revised on 04/18/22 revealed Resident #95 utilized nicotine products and had a history of concealing smoking materials and attempting to smoke inside the facility. Interventions included complete smoking evaluation, educating resident/resident representative on the smoking policy, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #95 required supervision while smoking. Observation on 11/28/23 at 11:08 A.M. of Resident #95 revealed the resident was outside the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 9 of 13 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 11/30/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility smoking with no staff present. Interview at the time of the observation with Nursing Staff Scheduler #149 confirmed Resident #95 was outside smoking. Nursing Staff Scheduler #149 reported the aide that was supervising the smoke area had gone to the bathroom. Review of the medical record for Resident #04 revealed he was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, congestive heart failure, vascular dementia moderate with other behavioral disturbance, other intervertebral disc degeneration, peripheral vascular disease, personality disorder, polyosteoarthritis, paranoid schizophrenia, and aphasia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #04 had significantly impaired cognition evidenced by a BIMS score of 06. This resident was assessed to require extensive assistance or supervision for ADLs. Review of the plan of care revised on 08/23/22 revealed Resident #04 utilized nicotine products. Interventions included complete smoking evaluation, educating resident/resident representative on smoking policy, smoke apron while smoking as ordered, and provide supervision during designated smoke times. Review of the smoking assessment dated [DATE] revealed Resident #04 required supervision and a smoking apron while smoking. Observation on 11/28/23 at 11:11 A.M. of Resident #04 revealed he was smoking without a smoking apron on and no staff present. Immediately after the observation, State Tested Nursing Assistant (STNA) #19 arrived in the area and confirmed Resident #04 was smoking without utilizing a smoking apron. Review of the facility policy titled Resident Smoking, reviewed 05/30/19, revealed a smoking apron is a fire-resistant apron used to cover the torso or body and lap to aid in preventing cigarettes ashes or dropped cigarettes from igniting clothing. The policy indicated smoking would only be in designated areas and supervised smoking would be performed by a staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 10 of 13 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 11/30/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected three (#95, #50 and #16) of five residents reviewed for unnecessary medications. The facility census was 137. Findings include: 1) Review of the medical record for Resident #95 revealed he was admitted to the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypertension, cardiomyopathy, hyperlipidemia, and insomnia. Review of the plan of care initiated on 04/18/22 for Resident #95, revealed the resident had pain related to generalized body pains, osteoarthritis, and muscle weakness. Interventions included following physician orders for complaints of pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #95, revealed the resident had severely impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 06. Review of the active physician orders dated 10/12/23 for Resident #95 revealed an order for Diclofenac Sodium external gel one percent to be applied to lower back topically every six hours as needed for pain. Review of the Pharmacist's Medication Regimen Review to the Physician/Prescriber dated 10/17/23 for Resident #95, revealed a recommendation to clarify the Diclofenac gel order and update the electronic health record for reflect dosage in grams. The recommendation was reviewed and approved by the physician on 10/20/23 and indicated the dosage in grams should be two grams. Interview on 11/30/23 at 4:04 P.M. with Regional Director of Clinical Operations (RDCO) #200 confirmed the physician's order for Diclofenac Sodium external gel was never updated per the pharmacist's recommendations to reflect the dosage in grams. 2) Review of the clinical record revealed Resident #50 was admitted to the facility originally on 01/20/23 and was readmitted on [DATE]. Her diagnoses included, but was not limited to, hypothyroidism, thyrotoxicosis with diffuse goiter, and myxedema coma. Review of the quarterly MDS assessment dated [DATE]. She had a BIMS score of 10 indicating she had moderate cognitive impairment. Review of the Pharmacist's Medication Regimen Review recommendations dated 10/17/23 for Resident #50, revealed the resident had an elevated thyroid stimulating hormone (TSH) (laboratory blood test to show the levels of thyroid hormone in the blood) in July 2023. The Pharmacist recommended another TSH level to be completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 11 of 13 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 11/30/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the active November 2023 physician's orders for Resident #50's, revealed the resident was ordered Levothyroxine Sodium oral tablet 150 micrograms (mcgs) by mouth each morning for hypothyroidism before breakfast. An additional order on 10/2/23/23 revealed the resident was ordered to have TSH level completed. Review of the laboratory (lab) results for Resident #50 revealed no documented evidence that a TSH level was completed per the physician's orders on 10/23/23 and there was no documentation of the resident refusing the lab test. Interview was conducted with the Director of Nursing (DON) on 11/30/23 at 3:22 P.M., verified the TSH levels for Resident #50 was not completed and there was no evidence that the resident refused to have the lab test completed. 3) Review of the medical record for Resident #16 revealed the resident was admitted on [DATE]. Diagnoses included congestive heart failure, paranoid schizophrenia, depression, mood disorder, psychotic disturbance, and delusional disorders. Review of active physician orders dated 02/03/22 for Resident #16 revealed the resident was ordered Ventolin Inhaler as needed (PRN) (rescue inhaler for respiratory issues). The Ventolin inhaler was not discontinued until 11/30/23 when a Surveyor questioned the order. Review of the September 2023 Pharmacist's Medication Regimen Review recommendations for Resident #16, revealed the resident had an active order for Ventolin Inhaler (inhaler for respiratory issues) as needed (PRN) that had not been used since it was ordered on 02/03/23 and in effort to reduce polypharmacy, the order should be reviewed and discontinued. The physician signed and approved the Pharmacist's recommendations on 09/28/23. Interview on 11/30/23 at 1:29 P.M. with the DON verified the order to discontinue Ventolin was missed and should have been discontinued in the month of September 2023. Review of the undated facility policy titled Medication Regimen Review revealed the pharmacist would report any irregularities to the attending physician, facility's medical director and director of nursing, and the reports must be acted upon in a timely manner that meets the needs of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 12 of 13 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 11/30/2023 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 137 residents in the facility. Findings Included: Review of the [NAME] PBJ staffing data report revealed the facility triggered for excessively low weekend staffing and a one star staffing rating for fiscal year quarter two of 2023. Interview with [NAME] President Analytics (VPA) #201 on 11/20/23 at 4:12 P.M. revealed the facility submitted the PBJ in the second quarter of 2023 and CMS has the wrong information. VPA #201 indicated the corporate team was working on the PBJ report and would resubmit it to CMS for the second quarter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365304 If continuation sheet Page 13 of 13