Health inspection·March 2, 2022

F 0550 was always continent of bowel and bladder. Level of Harm - Minimal harm or potential for actual harm Review of Resident #34's plan of care dated 02/16/22 revealed the plan was silent for goals or interventions related to assistance with activities of daily living. Residents Affected - Few Observation on 02/17/22 at 8:37 A.M. revealed Resident #34 was propelling himself in his wheelchair in the hallway going toward the administrative offices. The resident was wearing light grey jogging pants and the pants appeared saturated from his knees to his waist. Observation and interview on 02/17/22 at 9:35 A.M. revealed Resident #34 was sitting in his wheelchair in the hallway by his room with signs of incontinence. The resident's light grey jogging pants remained saturated from below the knee up to urine stains on his pink, button-up shirt. Interview with the Resident #34 revealed he had wet himself this morning and was not able to change because he did not have any clothes. Continued observation from 9:35 A.M. until 10:13 A.M. of Resident #34's room revealed the resident's entry door was open and the resident's bathroom door was open and Resident #34 could be seen from the hallway through the bathroom door standing at the sink without any clothes on. There were no staff observed assisting the resident or checking on the resident. Observation on 02/17/22 at 10:13 A.M. revealed Resident #34 put on his bathroom call light. Observation revealed at 10:14 A.M., State Tested Nursing Assistant (STNA) #50 entered the room. STNA #50 left the resident's room and returned to the room with gloves and bags. Interview on 02/17/22 at 10:25 A.M. with STNA #66 confirmed she was aware of Resident #34's incontinence earlier in the morning. STNA #66 stated she spoke to Resident #34 around 7:30 A.M. and encouraged him to return to his room and to change his clothes. STNA #66 stated Resident #34 told her he did not have any clothes to change into. STNA #66 confirmed she had not looked for any clothing for Resident #34. Interview and observation at 10:35 A.M. with Resident #34 revealed he had on clean dry clothing. The resident's wet and soiled clothing remained on the floor of the bathroom and on the floor in front of his bed. When the resident was asked if the STNA had assisted him, the resident replied, he cleaned himself up. The resident confirmed the STNA #50 found a pair of pants and a shirt in his drawer. Resident #34 stated he had an accident (bowel incontinence) and had to put on the call light to get help to clean up the mess from the incontinence. Observation of the resident's bathroom revealed the resident's wet clothing remained on the floor of the bathroom and on the floor in front of the resident's bed. Further observation revealed there was fecal matter/smears all over the toilet seat. Interview on 02/17/22 at 10:37 A.M. with STNA #50, revealed she was sitting at the nursing station and confirmed she had answered Resident #34's call light. STNA #50 stated the resident had bowel incontinence in the bathroom and needed help with cleaning up the mess. STNA #50 stated Resident #34 was independent and did not require her help to get cleaned up or get dressed. STNA #50 stated it was responsibility of the STNAs to clean the bathroom. STNA #50 was informed of the current condition of the resident's bathroom toilet seat. Interview on 01/17/22 at 1:21 P.M. with the Director of Nursing (DON) revealed she had observed Resident #34 at 7:20 A.M. and he was not incontinent at that time. The DON revealed Resident #34 was independent. Review of the resident's Minimum Data Set with the DON revealed Resident #34 required limited assistance with one-person assist for toileting and dressing. Review of Resident #34's plan of care with the DON confirmed the plan was silent for goals and interventions related to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0550 Level of Harm - Minimal harm or potential for actual harm resident's assistance with toileting, dressing or activities of daily living. The DON confirmed dignity and respect concerns were identified. Review of the facility's policy titled Quality of Life - Dignity, dated 09/01/18, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents Affected - Few This deficiency substantiates Complaint Numbers OH00114244, OH00112586, and OH00111693. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 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** 2. Review of medical record revealed Resident #325 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus, amputation of right leg above the knee, congestive heart failure, peripheral vascular disease, chronic ischemic heart disease, transient ischemic attack, atherosclerotic heart disease, coronary angioplasty implant and graft, cerebral infarction, and old myocardial infarction. Review of the physician order, dated 02/09/22, revealed Resident #325 had an order for do not resuscitate comfort care arrest (DNRCC-Arrest). Review of the paper form for the advance directives for Resident #323 revealed the form was not completed by the attending physician with the residents' consent at the time of admission. Interview on 02/17/22 at 9:48 A.M. with Licensed Practical Nurse (LPN) #49 confirmed the form should be completed when the resident was admitted to the facility. Review of the facility's policy titled Advance Directives, dated 12/2016, revealed upon admission information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Based on medical record review, staff interview, and policy review, the facility failed to ensure advance directives were accurate. This affected two (#53 and #325) of 18 residents reviewed for advance directives. The facility census was 70. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 05/07/19. Diagnoses included chronic obstructive pulmonary disease, hemiplegia, type two diabetes mellitus without complications, transient cerebral ischemic attack, peripheral vascular disease, epilepsy, chronic pain syndrome, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22, revealed Resident #53 had moderately impaired cognition. Review of the current physician orders in the electronic health record revealed an order for do not resuscitate comfort care (DNRCC), dated 04/22/21. Review of the plan of care, revised 06/09/21, revealed the resident had a code status of DNRCC. Review of the resident's paper health record revealed a do not resuscitate form that indicated the resident had a code status of DNRCC that was not signed by a physician. The form had the words 'Full Code' written on it as well. Interview on 02/17/22 at 9:05 A.M. with the Administrator confirmed the discrepancy regarding the code status for Resident #53. Review of the facility's policy titled Advance Directives, revised 12/2016, revealed the plan of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0578 care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 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: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, resident and staff interviews, review of the facilities policy, the facility failed to provide a safe, clean comfortable and homelike environment. This affected five (Residents #05, #38, #41, #422, and #423) of 18 residents reviewed for a homelike environment. The facility census was 70. Findings include: During interview with Residents #05 and #41 on 02/15/22 at 4:01 P.M. revealed the long wall where the resident's dressers and televisions were located revealed there were large areas of the drywall damaged. Observations also revealed the wall where the window was located had numerous damaged areas of drywall and the wall behind the resident's bed had large areas of damaged drywall. Resident #41 stated the walls had been in disrepair for long time. During observation of Residents #422 and #423's room on 02/15/22 at 4:30 P.M. revealed large areas of mold on the window blinds and the toilet was unsecured from the flange and moved side to side. The window blinds were directly over the heating air condition (HVAC) unit in the wall. Both residents were ambulatory and independent with toileting. During observation of Residents #38's room on 02/15/22 at 4:40 P.M. revealed the toilet was unsecured from the flange and moved side to side. Resident was independently mobile with toileting. During an interview with Maintenance Director #71 on 02/17/22 at 3:50 P.M. verified the above observations in Resident #05, #41, #422, #423, and #38's rooms. Maintenance Director #71 stated he was not aware of the areas in disrepair. Review of the facility's policy titled Maintenance Service, dated 12/01/09, revealed maintenance services shall be provided to all areas of the building, grounds and equipment. Functions of maintenance personnel included ensuring the building was in compliance with current federal, state and local laws regulations and guidelines and maintaining the building in good repair and free from hazards. This deficiency substantiates Complaint Numbers OH00115652, OH00114126, OH00113809, OH00113354, OH00112586 and OH00111693. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, review of the facility's policy, and staff interview, the facility failed to complete a discharge care plan for a resident. This affected one (Resident #324) of three residents reviewed for discharge care planning. The facility census was 70. Residents Affected - Few Findings Include: Record review for Resident #324 revealed an admission date of 01/27/22. Diagnoses included Coronavirus 19 (COVID-19), diabetes mellitus type II, local infection of the skin and subcutaneous tissue, gangrene, cutaneous abscess of right foot, essential primary hypertension, hyperlipidemia, obesity, methicillin susceptible staphylococcus aureus, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Resident #324's care plans revealed he did not have a care plan in place regarding discharge planning. Interview on 02/15/22 at 2:55 P.M. with MDS Nurse #26 confirmed Resident #324 did not have a discharge care plan in place. MDS Nurse #26 confirmed the discharge planning begins upon admission and was usually completed. Interview on 02/15/22 at 3:01 P.M. with the Social Worker (SW) #01 confirmed Resident #324 did not have a discharge care plan in place. SW #01 confirmed the discharge planning should be completed upon admission. Review of the facility's policy titled Care Plans, Comprehensive Person- Centered, dated December 2016, revealed, it will contain information regarding discharge planning. It stated it should include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals to local agencies or other entities to support such desire. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were administered as ordered. This affected two (#53 and #324) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: 1. Record review for Resident #324 revealed an admission date of 01/27/22. His diagnoses included diabetes mellitus II, local infection of the skin and subcutaneous tissue, gangrene, cutaneous abscess of right foot, methicillin susceptible staphylococcus aureus, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 02/03/22, revealed Resident #324 had intact cognition. Review of the Medication Administration Review (MAR) dated February 2022 revealed the following information regarding missed dosages of medication for Resident #324: • Ceftriaxone sodium solution reconstituted (antibiotic) two gram intravenously one time a day related to cutaneous abscess of right foot until 02/17/22. One dose was missed on 02/11/22. A note was written in the progress notes that Ceftriaxone sodium solution was unable to be administered due to medication was exhausted from the e-box and despite several attempts to refill it from the pharmacy. The pharmacy is not sending the medication to the facility. • Duloxetine HCl capsule delayed release sprinkle 60 milligrams (mg) one capsule by mouth one time a day for depression. It was not administered three times on 02/02/22, 02/04/22, and 2/07/22. • Flush intravenous (IV) catheter after antibiotic with 10 milliliter (ml) syringe of normal saline (NS) followed by five ml of Heparin Flush (used to flush out IV catheter, which helps prevent blockage in the tube after an IV infusion) every day. It was not administered on three days on 02/06/22, 02/09/22, and 02/11/22. It was marked at unavailable. • Trulicity Solution Pen-injector 0.75 mg/ 0.5 ml inject 0.5 ml subcutaneously one time a day every Thursday related to Type II diabetes mellitus with diabetic polyneuropathy. It was not administered on 02/03/22. Interview on 02/15/22 at 04:00 P.M. with the Unit Manager Nurse (UMN) #29 confirmed if a nurse did not write a progress note in Resident #324's chart regarding a missed medication then they nurse must have gotten busy and forgot to administer the medication. UMN #29 confirmed there was no note or information regarding Resident #324 missing medications of Duloxetine, Heparin Flush or Trulicity. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0755 Level of Harm - Minimal harm or potential for actual harm UMN #29 stated the facility continues to have ongoing issues with pharmacy. UMN #29 stated the facility ordered Resident #324's antibiotic however the pharmacy did not deliver it. UMN #29 stated the facility exhausted their supply of the medication. UMN #29 stated the facility nurses should have documented notifying the physician and family regarding the missed doses of medications. UMN #29 confirmed Resident t #324 did not receive the antibiotic as physician ordered. Residents Affected - Few 2. Record review for Resident #53 revealed an admission date of 05/07/19. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, contracture of left wrist, and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/11/22, revealed Resident #53 had moderately impaired cognition. Review of the current physician orders revealed an order for Tramadol HCI tablet 50 milligrams that indicated one tablet was to be given by mouth four times a day related to chronic pain. Review of the Medication Administration Record (MAR) for 02/2022 revealed on 02/19/22 for the 9:00 P.M. dose, the MAR indicated other/see nurse notes. Review of the nursing progress notes dated 02/19/22 revealed the medication was unavailable. Registered Nurse (RN) #150 received an authorization code to obtain the medication from the automated medication dispensing system at the facility but there was not another nurse with access to the system, so the medication was unable to be pulled. Interview on 02/24/22 at 2:15 P.M. with RN #150 verified Resident #53 did not receive the Tramadol as ordered. She stated she had access to the system, but two nurses with access were required to verify a narcotic. She reported no other nurses were working at the time to access to the system. Review of the facility's policy titled Documentation of Medication Administration, dated 07/01/2019, revealed the facility shall maintain administration record to document all medications administered. Section F of the policy stated, Reason(s) why a medication was withheld, not administered, or refused (as applicable). This deficiency substantiates Complaint Numbers OH00114487, OH00114244, and OH00111693. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interviews, record review, and review of the facility's policy, the facility failed to provide food that was served at a safe and appetizing temperature. This had the potential to affect the two residents (#18 and #426) who were on a pureed diet. The facility census was 70. Residents Affected - Few Findings included: During observations of the lunch pre-service food temperatures on 02/16/22 at 11:28 A.M. revealed [NAME] #22 checked the puree chicken and recorded a holding temperature of 108 degrees Fahrenheit (F) on the Daily Food Temp Log. Review of the completed temperature log with [NAME] #22, immediately as she completed temperature checks, [NAME] #22 confirmed she received and recorded the temperature of 108 degrees F for the puree chicken. [NAME] #22 stated Residents #18 and #426 were only two residents on a puree diet. During continued observations of the kitchen and follow-up interview with [NAME] #22 on 02/16/22 at 12:20 P.M. and review of the lunch temperature logs, the log appeared to have been changed to show the chicken was 188 degrees F. [NAME] #22 again confirmed the puree chicken was 108 degrees F when she checked it at 11:28 A.M. and did not change the log. During an observation of food service on 02/16/22 at 12:22 P.M. revealed the food cart with Resident #18's tray had exited the kitchen. Dietary Manager (DM) #23 and Registered Dietitian (RD) #101 walked with the trays as they were being delivered. RD #101 indicated at minimum, the holding temperature should have been 135 degrees F. Observation of the puree chicken directly before the meal was going to be delivered to Resident #18 with DM #23 revealed the puree chicken was 110 degrees F. Surveyor mentioned the recorded 108-degree temperature F in the kitchen by [NAME] #22, and RD #101 indicated that was not appropriate. DM #23 removed the tray for Resident #18 and returned to the kitchen to reheat the food. During an interview with RD #101 on 02/16/22 at 12:45 P.M. indicated [NAME] #22 should have addressed the 108 temperatures F before allowing the puree chicken to leave the kitchen. RD #101 verified the puree chicken was under the appropriate temperatures to be served. Review of the facility's policy titled Preventing Foodborne Illness-Food Handling, dated 07/01/14, revealed food will be stored, handled and served so that the risk of Foodborne illness is minimalized. This deficiency substantiates Complaint Numbers OH00113809, OH00113354, OH00114126, and OH00114244. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy, observations and resident and staff interviews, the facility failed to a resident received the appropriate diet for her food allergy. This affected one (#322) of 18 residents reviewed for food quality. The facility census was 70. Findings include: Review of Resident #322's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included celiac disease. Allergies listed included gluten. Review of the physician orders, dated 02/06/22, revealed a diet order for a heart healthy (cardiac) diet, regular texture, thin consistency. Observations on 02/14/22 at 12:20 P.M. revealed a Styrofoam food container on a tray for Resident #322. A piece of toast was sticking out of the container. Interview on 02/14/22 at 12:24 P.M. with Resident #322 stated she couldn't eat a lot of the food that was served to her. She stated the kitchen provides the incorrect diet to her and explained she was gluten intolerant. She stated the kitchen has been serving her pancakes, waffles, and pasta. Observations on 02/15/22 at 8:50 A.M. revealed Resident #322 had a breakfast tray on her over the bed table. The resident was eating scrambled eggs, bacon, and rice cereal. Two biscuits were on the residents' plate. Interview on 02/16/22 at 3:32 P.M. with Registered Dietitian (RD) #101 verified Resident #322 was on a gluten free diet and presented the meal ticket for Resident #322 showing the diet as gluten free with no bread, pasta or rolls. RD #101 stated the facility did not have gluten free biscuits, pasta, or bread. Review of the facility's policy titled Tray Identification, dated 04/200,7 revealed the Food Service Manager or supervisor would check trays for correct diets before the food carts were transported to their designated areas. This deficiency substantiates Complaint Number OH00114244. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 interviews, record review, and review of the facility policies, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 69 of 70 residents residing in the facility, excluding Resident #50 who received enteral feedings and nothing by mouth. Findings include: 1. An initial tour of the kitchen was conducted on 02/14/22 at 9:45 A.M. with [NAME] #22. While touring the kitchen, the following was observed: 1a. The free-standing walk-in freezer located outside of the building with [NAME] #22 felt very warm and observation revealed a non-functioning thermometer sitting on the shelf. Continued observation revealed the ice cream was completely liquefied, the tater tots, French fries and all vegetables were very soft to touch. [NAME] #22 stated she last got something from the freezer at 5:45 A.M. and everything seemed to be working normally. [NAME] #22 verified the freezer was not working, non-functioning thermometer and numerous food items were thawed and liquefied. 1b. The common ice machine located in the common area and directly outside the kitchen and available for any resident to retrieve ice had a significant amount of mold accumulation on the upper inside area of the hopper where the ice was dispensed into reservoir. [NAME] #22 verified the presence of the mold and [NAME] #22 stated she was not sure who was responsible for cleaning the machine and when the last cleaning was completed. 1c. The facility was equipped with a high temperature dish machine with manufacturer's minimum wash recommendations at 150 degrees Fahrenheit (F) and rinse operating temperatures of 180 degrees F. The dishwasher log for February 2022 was blank for any dishwasher temperatures being recorded. [NAME] #22 verified there were no recorded temperatures for dishwasher and stated she was not sure who tested the dishwasher temperatures. 1d. The kitchen had three empty buckets used for sanitizing food preparation and contact surfaces which were stacked inside each other and on a shelf. [NAME] #22 stated the facility did not use the sanitizer buckets and kitchen used a spray bottle of mixed bleach to clean. [NAME] #22 stated she did not know how the kitchen tested the solution. 2. A follow-up tour of the central kitchen was conducted on 02/15/22 at 3:10 P.M. While touring the kitchen the following was observed: 2a. The three-sink cleaning/disinfecting system revealed the sanitized section was filled with a clear liquid. Interview with Dietary Aid (DA) #21 indicated the kitchen staff used the sanitized section of the sink to clean items not able be run through the dishwasher. DA #21 stated the kitchen did not have any testing strips to test the chemical in the three-sink cleaning/disinfecting system. Further observations of the form hanging above the sink titled Sanitizer Log -2022 revealed the last date recorded on the form was 02/06/22 and completed by DA #21. DA #21 stated the facility was out of sanitizer to put in the sink so he filled the sink with plain water to rinse the dishes. DA #21 verified the kitchen had been out of sanitizer since 02/06/22 and verified the log was absent for testing the sanitizer levels since 02/06/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 2b. The kitchen had one sanitizer bucket sitting on a shelf with clear liquids and DA #21 stated Dietary Manager (DM) #23 had made up the sanitizer bucket earlier in morning. DA #21 stated the sanitizer bucket was made up with bleach and water. DA #21 stated the kitchen used spray bottles of bleach to clean the kitchen. DA #21 stated the facility had no way of testing the bleach mixture solution and followed no formula for making up the solutions. DA #21 stated he just added some bleach and water to bottle. Observation at the same time with DA #21 revealed the solution in spray bottles and bucket had no odor of bleach. When asked to observe the bleach he used, DA #21 stated he did not have any bleach in the kitchen. Interview with DM #23 at same time indicated she made up the bucket with bleach and water when she arrived around 6:00 A.M. DM #23 confirmed the facility still had no sanitizer solution for sinks or the sanitizer buckets. DM #23 stated the Sanitizer solution was still on order and should be delivered on 02/16/22. During an interview with the Administrator on 02/15/22 at 3:30 P.M. indicated she was not aware the kitchen did not have any sanitizer. Interview with Infection Preventionist (IP) /Licensed Practical Nurse (LPN) #30 on 02/15/22 at 4:00 P.M. indicated she was never instructed the kitchen was out of sanitizer. LPN #30 stated her expectations indicated being notified if/when the kitchen was out of sanitizer to monitor for any gastrointestinal issues (GI) related to food borne illness. LPN #30 denied any knowledge of GI related issues in the facility. Subsequent interview with DM #23 on 02/16/22 at 10:00 A.M. indicated the facility had not received the shipment of sanitizer. DM #23 further stated she had not notified the Administrator, Director of Nursing (DON) and/or or the IP/ LPN #30 when the kitchen ran out of sanitizer. DM #23 stated she only instructed the Maintenance Director so he could order more. DM #23 stated she was not aware she had to notify the nursing staff and stated she did not understand why she needed to notify them. Subsequent interview with the Administrator on 02/16/22 at 10:30 A.M. indicated she did not address the kitchen not having sanitizer but would address it immediately. 3. A follow-up tour of the kitchen was conducted on 02/16/22 at 11:28 A.M. While touring the kitchen, the following was observed: 3a. There continued to be no sanitizer solution for the kitchen and the kitchen was still using bleach and water solution with no way to test the solution and/or a formula for mixing the solution in a spray bottle and sanitizer buckets. Interview with DM #23 at same time verified the facility had not received the shipment for the sanitizer solution. 3b. Observation of meal preparation, service, and tray assembly on 02/16/21 beginning at 11:45 A.M. revealed food temperature logs for 02/10/22 through 02/14/22 were blank. [NAME] #22 verified there were no recorded temperature checks for the foods being served. 3c. During preparation of delivery of trays, DA #18 was putting the food trays with drinks inside an open rolling cart and once completed, DA #18 pushed the cart from the kitchen and when the door to the kitchen opened, the air/pressure pushed numerous meal tickets off the resident's food trays and on to the floor. DA #18 and Registered Dietitian (RD) #101 started sorting and putting the meal tickets back on the food trays by lifting the plates and putting the tickets under the plates. Once completed with sorting out the meal tickets, DA #18 stated the trays were ready for delivery. DA #18 exited the kitchen and pushed the food cart to the East section of the facility. RD #101 walked to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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 East section of the facility and when DA #18 delivered trays. Directly before staff started pulling the trays from the cart, the surveyor intervened due to the infection control issue from the meal tickets falling on the floor, RD #101 confirmed it was an infection control issue from the meal tickets falling on the floor. RD #101 instructed DA #18 to return the trays to the kitchen. RD #101 and DA #18 verified the infection control issue. DA #18 stated the facility had clear plastic covers to put over the open cart during delivery but forgot due to being in a hurry. 4. Continued observation of kitchen on 02/16/22 at 12:30 P.M. reveled numerous new bottles of food service grade industrial cleaner bottles. Interview with DM #23 at the same time indicated the Administrator purchased the pre-mixed cleaning solutions until the bulk sanitizer was delivered. Interview with DM #23 on 02/16/22 at 1:05 P.M. revealed her expectations were for the dishwasher temperature logs be completed and food should be checked for appropriate temperatures at every meal service and recorded. Surveyor asked DM #23 for copies of food temperature logs from 02/10/22 through 02/14/22. At 1:09 P.M., the surveyor entered the kitchen to ask DM #23 a question and observed DA #21 and [NAME] #22 standing with the temperature log book and DA #21 holding a pen and writing on the log dated 02/11/22. DA #21 stated he was just looking at them but when the surveyor reviewed the logs, 02/10/22 and 02/11/22 had been filled in with temperatures. Surveyor questioned DA #21 if he had filled in the logs and DA #21 stated he did not despite observing him writing on the 02/11/22 log and already having the blank logs verified by the staff. Interview with DM #23 at same time indicated she only instructed [NAME] #22 to make a copy of the logs since it was her responsibility. Interview with RD #101 on 02/16/22 at 1:10 P.M. indicated food temperatures should be completed and logged at each meal service. Review of the facility's list of residents who were nothing by mouth (NPO) revealed Resident #50 was NPO. Review of the facility's policy titled Sanitization, dated 10/01/08, revealed the food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensil shall be washed to remove or completely loosen soils by using the manual or mechanical mean necessary and sanitized using hot water and/or chemical sanitizing solutions. Sanitizing of environmental surfaces must be performed with on the following solutions: 50-100 parts per million (ppm) of chlorine solution, 150-200 ppm quaternary ammonium compound (QAC) or 12.5 ppm iodine solution. Ice machines will be drained, cleaned, and sanitized per manufacturers instructions. Food service staff would be responsible for cleanliness of the kitchen. Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, dated 07/01/14, revealed food would be stored, prepared handled and served so that the risk of foodborne illness was minimized. All food service equipment and utensils will be sanitized according to the current guidelines and manufactures recommendations. Review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 10/01/17, revealed food and nutrition employee would follow appropriate hygiene and sanitary procedures to prevent he spread of foodborne illness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365327 If continuation sheet Page 14 of 14