Health inspection·April 18, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 04/16/19 at 12:35 P.M., Resident #107 was asked if she had any advanced directive and if so what she had chosen. She stated that she had requested to be a Full Code. A follow-up interview was conducted with RN #42 on 04/17/19 at 3:52 P.M. regarding the discrepancy between Resident #107's advanced directive information present in the electronic health record and the hard chart. She stated when an order is written, or a resident makes an choice regarding an advance directive, the order is written and added to the electronic health record. RN #42 stated then a sticker consistent with the advanced directive is added to the inside cover of the hard chart, and if a DNR the paper work usually signed by the resident and their physician is added to the hard chart. When asked where staff if supposed to check first in an emergency, she stated that the hard chart was faster in an emergent situation. The facility's policy and procedure titled Advance Directives, revised on 11/2017 was requested and reviewed. The policy specified the facility would recognize an individual's right under state law to make decision concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365423 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility in September of 2016 with current diagnoses including Parkinson's disease, unspecified dementia with behavioral disturbance, repeated falls, difficulty in walking, major depressive disorder, and degenerative diseases of the nervous system. The facility completed a quarterly minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 03/04/19. The 03/04/19 assessment identified the resident as having moderately impaired cognitive skills, behavioral symptoms not directed towards others, required limited assistance to transfer, and was able to self-propel her wheel chair with supervision and oversight. Resident #20 was observed propelling herself about in her room, and on the first floor on the facility to and from the dining room over three days of survey. Review of Resident #20's current comprehensive plan of care revealed a care plan to address the resident's problem/need related to having impaired cognitive function/dementia or impaired through processes related to placement of deep brain stimulator and Parkinson's. The goal was for the resident to be able to communicate basic needs on a daily basis, and to maintain her current level of functioning through the review date of 07/15/19. Interventions included but were not limited to applying a security transmitter for wandering (wander guard) to the resident's wheel chair, and to check the placement and the function of the wander guard every shift. Review of the Resident #20's nursing progress notes revealed an entry by Registered Nurse (RN) #46 on 03/02/19 at 8:27 A.M. RN #46 documented the resident was up in her wheel chair and noted going towards the back door stating she was going to go home to start my life over. The nurse documented the resident was easily redirected to the dining room, and a new order was obtained to apply a wander guard to the resident's wheel chair. RN #46 documented the wander guard was applied and was functional at that time. On 03/02/19, RN #46 completed an elopement risk assessment for Resident #20. RN #46 noted on the assessment that a wander guard was applied to the resident's wheel chair today. The resident was verbalizing she was going home to start her life over, and was observed by staff going to the door twice. Resident #20's treatment record was requested from the DON and reviewed. The treatment record, printed at 9:13 A.M., indicated that Licensed Practical Nurse (LPN) #22 had marked on the electronic record that he had already checked the placement and function of the wander guard to the wheel chair for the 04/17/18 first shift of duty; 7:00 A.M. to 7:00 P.M. An interview was conducted with LPN #22 on 04/17/19 at 3:09 P.M. regarding any attempt by the resident to leave the facility. He confirmed the resident is up and does move about the facility on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365423 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230 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 0656 own, but had never observed the resident attempting to leave or stating she was going to leave. Level of Harm - Minimal harm or potential for actual harm On 04/17/19 at 3:25 P.M. a follow-up interview was conducted with LPN #22 regarding Resident #20's wander guard i.e. security transmitter. When asked if the residents had a wander guard device. LPN #22 stated he was unsure and went to check the resident and reported he did not find one. The LPN #22 then went with the surveyor to look at the resident's chair. There was a wander guard device affixed to the lower frame of the resident's wheel chair. LPN #22 was then asked how he checked the wander guard device to make sure it was functioning he did not reply but stated he would find out. LPN #22 then returned and reported to the surveyor on 04/17/19 at 3:34 P.M. that there were two ways to check the wander guard devices for proper function. He stated that one way was for to roll the resident close to a door equipped with a wander guard receiver i.e. the front door, and use the portable device. When asked how he had checked off that he had checked Resident #20's wander guard device for placement and function already today, if he did not know one was there or how to check it, he smiled and said he was going to today. Residents Affected - Few On 04/17/19 at 3:43 P.M. LPN #22 reported to the surveyor that the wander guard transmitter/receiver device was just to check the doors equipped with the wander guard devices for function, that to test a resident's wander guard device for function you have to take the resident near a door equipped with a wander guard. On 04/17/19 5:22 P.M. LPN #22 checked Resident #20's wander guard security transmitter. He asked the resident if it was okay to wheel her near the front door on the way to the main dining room. As Resident #20 approached the set of front doors an alarm sounded and the doors latched. Observation of the facility's door security devices revealed that first floor two exit access doors, the front doors/main entrance and the exit door from the dining room, were equipped with wander guard security receivers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365423 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility in September of 2016 with current diagnoses including Parkinson's disease, unspecified dementia with behavioral disturbance, repeated falls, difficulty in walking, major depressive disorder, and degenerative diseases of the nervous system. The facility completed a quarterly minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 03/04/19. The 03/04/19 assessment identified the resident as having moderately impaired cognitive skills, behavioral symptoms not directed towards others, required limited assistance to transfer, and was able to self-propel her wheel chair with supervision and oversight. Resident #20 was observed propelling herself about in her room, and on the first floor on the facility to and from the dining room over three days of survey. Review of Resident #20's current comprehensive plan of care revealed a care plan to address the resident's problem/need related to having impaired cognitive function/dementia or impaired through processes related to placement of deep brain stimulator and Parkinson's. The goal was for the resident to be able to communicate basic needs on a daily basis, and to maintain her current level of functioning through the review date of 07/15/19. Interventions included but were not limited to applying a security transmitter for wandering (wander guard) to the resident's wheel chair, and to check the placement and the function of the wander guard every shift. Review of the Resident #20's nursing progress notes revealed an entry by Registered Nurse (RN) #46 on 03/02/19 at 8:27 A.M. RN #46 documented the resident was up in her wheel chair and noted going towards the back door stating she was going to go home to start my life over. The nurse documented the resident was easily redirected to the dining room, and a new order was obtained to apply a wander guard to the resident's wheel chair. RN #46 documented the wander guard was applied and was functional at that time. On 03/02/19, RN #46 completed an elopement risk assessment for Resident #20. RN #46 noted on the assessment that a wander guard was applied to the resident's wheel chair today. The resident was verbalizing she was going home to start her life over, and was observed by staff going to the door twice. Resident #20's treatment record was requested from the DON and reviewed. The treatment record, printed at 9:13 A.M., indicated that Licensed Practical Nurse (LPN) #22 had marked on the electronic record that he had already checked the placement and function of the wander guard to the wheel chair for the 04/17/18 first shift of duty; 7:00 A.M. to 7:00 P.M. An interview was conducted with LPN #22 on 04/17/19 at 3:09 P.M. regarding any attempt by the resident to leave the facility. He confirmed the resident is up and does move about the facility on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365423 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Washington Care Center 6900 Beechmont Avenue Cincinnati, OH 45230 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 own, but had never observed the resident attempting to leave or stating she was going to leave. Level of Harm - Minimal harm or potential for actual harm On 04/17/19 at 3:25 P.M. a follow-up interview was conducted with LPN #22 regarding Resident #20's wander guard i.e. security transmitter. When asked if the residents had a wander guard device. LPN #22 stated he was unsure and went to check the resident and reported he did not find one. The LPN #22 then went with the surveyor to look at the resident's chair. There was a wander guard device affixed to the lower frame of the resident's wheel chair. LPN #22 was then asked how he checked the wander guard device to make sure it was functioning he did not reply but stated he would find out. LPN #22 then returned and reported to the surveyor on 04/17/19 at 3:34 P.M. that there were two ways to check the wander guard devices for proper function. He stated that one way was for to roll the resident close to a door equipped with a wander guard receiver i.e. the front door, and use the portable device. When asked how he had checked off that he had checked Resident #20's wander guard device for placement and function already today, if he did not know one was there or how to check it, he smiled and said he was going to today. Residents Affected - Few On 04/17/19 at 3:43 P.M. LPN #22 reported to the surveyor that the wander guard transmitter/receiver device was just to check the doors equipped with the wander guard devices for function, that to test a resident's wander guard device for function you have to take the resident near a door equipped with a wander guard. On 04/17/19 5:22 P.M. LPN #22 checked Resident #20's wander guard security transmitter. He asked the resident if it was okay to wheel her near the front door on the way to the main dining room. As Resident #20 approached the set of front doors an alarm sounded and the doors latched. Observation of the facility's door security devices revealed that first floor two exit access doors, the front doors/main entrance and the exit door from the dining room, were equipped with wander guard security receivers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365423 If continuation sheet Page 6 of 6