Inspection·January 10, 2019

F 0550 #111 told him, you need to be able to do that. Resident #56 stated that he told STNA #111, I'll show you. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator and the DON on 01/07/19 at 5:47 P.M. revealed the Administrator and the DON were made aware of an inappropriate conversation that occurred between Resident #56 and STNA #111 on 09/27/18. The DON reported STNA #111 and Resident #56 were joking back and forth when STNA #111 made an inappropriate comment regarding the last time Resident #56 had a sexual encounter. The DON reported she interviewed Resident #56 and he was not upset by the comment. The DON stated Resident #56 told STNA #111 that he would show her in a joking manner after STNA #111 made the comment to Resident #56. The DON reported she did not report the incident as an Self-Reported Incident (SRI) due to the comments being made in a joking manner instead of in an abusive manner. Residents Affected - Few Interview with Resident #56 on 01/09/19 at 2:41 P.M. revealed resident to report no instances of being verbally abused, disrespected or treated in an undignified manner by the staff at the facility. Interview with Dietary Technician #54 on 01/09/19 at 2:34 P.M. revealed STNA #111 and Resident #56 were talking back and forth in a joking manner on 09/27/18. Dietary Technician #54 reported she became concerned because STNA #111 made an inappropriate comment to Resident #56 regarding the last time he had a sexual encounter. Dietary Technician #54 reported she went out in the hallway to speak to STNA #111 about the comment and found STNA #111 to be walking down the hallway. Dietary Technician #54 stated she reported the incident to the Administrator. Dietary Technician #54 reported the comment was not verbally abusive towards Resident #54 due to Resident #56 and STNA #111 making comments back and forth in a joking manner. Interview with Activities Director #110 on 01/10/19 at 9:30 A.M. revealed she was in the office on 09/27/18 when she heard STNA #111 and Resident #56 talking to each other. Activities Director #110 reported Resident #56 was agitated on that date. Activities Director #110 stated she became concerned after STNA #111 made a comment about Resident #56's last sexual encounter. Activities Director #110 stated she went out into the hallway after the comment was made to address the situation and STNA #111 and Resident #56 had already left the hallway. Activities Director #110 reported she did not feel the comment that STNA #111 made to Resident #56 about his last sexual encounter was appropriate, but she did not feel it was abusive due to the comment being made in a joking manner. Interview with STNA #111 on 01/10/19 at 10:31 A.M. revealed she and Resident #56 were joking back and forth due to her having a good rapport with the resident. STNA #111 reported Resident #56 stated, F*ck you and she said, now when is the last time you did that. STNA #111 reported Resident #56 told her that he was going to show her something. STNA #111 then told the resident, You go on back down the hallway and they both laughed. Review of the facility's Quality of Life-Dignity policy dated August 2009 revealed residents should be treated with dignity and respect at all times. The policy also reported staff shall speak respectfully to residents at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review the facility failed to provide a copy of the notification of transfer or discharge to the Ombudsman for residents that discharged to the hospital. This affected two (#24 and #39) of three residents reviewed for discharge notification. The facility census was 95. Findings include: 1. Record review revealed Resident #24 was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, alcohol use, major depressive disorder, seizures, hypertension, low back pain, carcinoma of colon and chronic obstructive pulmonary disease. Review of Resident #24's 14-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #24 was also independent with eating. Further review of Resident #24's record revealed the resident was discharged to the hospital on [DATE] for the removal of a gastrointestinal mass. Resident #24 was reported to readmit to the facility from the hospital on [DATE]. Review of a list of names that was faxed to the Ombudsman's office on 11/01/18 revealed Resident #24's discharge was not reported to the Ombudsman. The list was discharges that occurred from 10/01/18 to 10/31/18. Interview on 01/08/19 at 3:51 P.M. with Corporate Nurse #300 verified the Ombudsman was not notified of Resident #24's discharge to the hospital on [DATE]. Corporate Nurse #300 reported the list of discharges sent to the Ombudsman from 10/01/18 to 10/31/18 was printed incorrectly and did not include Resident #24's discharge. 2. Record review revealed Resident #39 was admitted to the facility on [DATE] with the following diagnoses; acute cholecystitis, rheumatoid arthritis, hypothyroidism, hypertension, low back pain, gastro esophageal reflux disease, asthma, symbolic dysfunctions, type two diabetes mellitus, major depressive disorder and chronic obstructive pulmonary disease. Review of Resident #39's quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and required limited assistance with transfers, and toileting. Resident #39 was also independent with bed mobility, dressing and eating and required supervision with personal hygiene. Further review of Resident #39's record revealed the resident was discharged to the hospital on [DATE] for knee surgery. Resident was reported to readmit to the facility from the hospital on [DATE]. Review of a list of names that was faxed to the Ombudsman's office on 10/02/18 revealed Resident #39's discharge was not reported to the Ombudsman. The list of discharges occurred from 09/01/18 to 09/30/18. Interview on 01/08/19 at 3:51 P.M. with Corporate Nurse #300 verified the Ombudsman was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete notified of Resident #39's discharge to the hospital on [DATE]. Corporate Nurse #300 reported the list of discharges sent to the Ombudsman from 09/01/18 to 09/30/18 was printed incorrectly and did not include Resident #39's discharge. Review of the facility's Transfer or Discharge Notice policy dated December 2016 revealed the Long Term Care Ombudsman will receive a copy of the resident's discharge or transfer notice within 30 days of discharge. Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed notify the state mental health authority or submit a significant change pre-admission screening and resident review (PASARR) for residents with a mental illness that had a significant change in their physical health. This affected two (#4 and #24) of two residents reviewed for significant change PASARR. The facility census was 95. Findings include: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with the following diagnoses; dementia without behavioral disturbance, major depressive disorder, anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, atrial fibrillation, sciatica, low back pain, allergic rhinitis, glaucoma, atherosclerotic heart disease, osteoarthritis, essential hypertension, mild cognitive impairment, hypertensive chronic kidney disease with stage five chronic kidney disease or end stage renal disease. Review of Resident #4's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing and toileting. Resident #4 also required total dependence with transfers, limited assistance with personal hygiene and supervision with eating. Review of Resident #4's PASARR dated 05/06/12 revealed the PASARR was obtained upon Resident #4's admission to the facility. Resident #4's medical record did not contain a significant change PASARR after his significant change on 10/02/18. Further review of Resident #4's record revealed the resident was admitted to counseling services on 11/16/18 and was receiving ongoing counseling services related to depression with psychotic features. Further review of Resident #4's record reveled resident was seen by Psychiatrist #310. Progress note from Psychiatrist #310 on 12/21/18 revealed the resident was seen for depression Interview on 01/08/19 at 3:51 P.M. with Corporate Nurse #300 verified the state mental health agency was not notified and a significant change PASARR was not completed upon Resident #4's significant change on 10/02/18. Corporate Nurse #300 reported Resident #4 had a significant change on 10/02/18 due to a significant weight loss, increased incontinence and increased need for assistance with activities of daily living (ADLs). 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, alcohol use, major depressive disorder, seizures, hypertension, low back pain, carcinoma of colon and chronic obstructive pulmonary disease. Review of Resident #24's significant change (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility, transfers, dressing, and personal hygiene. Resident #24 was also independent with eating and required extensive assistance with toileting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident #24's PASARR dated 04/04/17 revealed the PASARR was obtained upon Resident #24's admission to the facility. Resident #24's record did not contain a significant change PASARR after his significant change on 10/01/18. Interview on 01/08/19 at 3:51 P.M. with Corporate Nurse #300 verified the state mental health agency was not notified and a significant change PASARR was not completed upon Resident #24's significant change on 10/01/18. Corporate Nurse #300 reported Resident #24 had a significant change on 10/02/18 due to a new colostomy, increased incontinence and increased need for assistance with activities of daily living (ADLs). Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of facility policy, the facility failed to ensure cautionary and safety signs were posted outside a resident's room where oxygen was in use. This affected one (#89) of 21 residents the facility identified as using oxygen. The facility census was 95. Residents Affected - Few Findings include: Resident #89 was admitted on [DATE] with diagnoses including paraplegia, anemia, diabetes mellitus, hypertension, and osteomyelitis of vertebra, sacral, and sacrococcygeal region. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, required supervision for eating and extensive assist to total dependence for activities of daily living. Review of the current physician orders revealed the resident had an order dated 01/06/18 for oxygen at 2 liters and to keep oxygen saturation above 90 percent as needed for shortness of breath. Interview on 01/07/19 at 8:40 A.M., the Administrator stated the facility was not a non-smoking facility and permitted residents to smoke in designated areas. Observation on 01/07/19 at 11:11 A.M. revealed Resident #89 in bed. An oxygen concentrator was on and running at 2 liters in the resident's room. There was not a no smoking/oxygen in use signage on or near the entrance to the resident's room. Interview on 01/07/19 at 11:14 A.M., Licensed Practical Nurse (LPN) #62 stated resident's who used oxygen were to have a sign on the entrance to the door. LPN #62 verified an oxygen concentrator was on in the resident's room, and that there was no cautionary or safety sign on the entrance to the resident's room. LPN #62 stated the oxygen order was initiated over the weekend and staff probably forgot to place the sign on the door. Review of the facility policy titled, Oxygen Administration dated October 2018 revealed the purpose of the procedure was to provide guidelines for safe oxygen administration and the facility was to place an Oxygen in Use sign on the outside of the room entrance door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews the facility failed to ensure one residents' eye drop medication was administered in accordance with physician orders. This affected one (#87) of three residents sampled who received eye drop medication. The facility identified 12 residents who received physician ordered eye drop medications. The facility census was 95 residents. Findings include: Resident #87 was admitted to the facility on [DATE] with diagnoses of anemia, heart failure, hypertension, peripheral vascular disease, non-Alzheimer's dementia and hemiplegia. Review of Resident #87's quarterly Minimum Data Set assessment dated [DATE] revealed he had moderate cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the ophthalmologist consult report dated 12/13/18 revealed he recommended Resident #87 receive Brimonidine Tartrate Solution 0.2% twice a day to his left eye (OS) for glaucoma. Review of the 12/2018 Medication Administration Record (MAR) documented the resident received one drop of Brimonidine Tartrate Solution 0.2% twice a day OS on 12/13/18. The MAR indicated the resident received one drop twice a day in his right eye (OD) from 12/14/18 to 01/08/18. On 01/09/19 at 9:30 A.M. an observation was made as Licensed Practical Nurse (LPN) #37 prepared to administer an eye drop to Resident #87. LPN #37 indicated she was going to administer one drop of Brimonidine Tartrate Solution 0.2% to the residents' OD. When she showed the bottle to the surveyor, the label indicated this eye drop was for the OS. LPN #37 was questioned as to which eye was the correct eye for the medication administration. The nurse did not know so she held the medication and checked with the Director of Nursing (DON). The MAR identified the eye drop should be administered to the OD and the label on the bottle documented the medication was for the OS. On 01/09/19 at 2:15 P.M. an interview with the DON revealed the medication should have been administered to the OS. She stated LPN #107 had changed the MAR for the resident to receive the Brimonidine Tartrate Solution 0.2% to the OD. The DON further explained on 12/13/18 the physician wrote to administer Brimonidine Tartrate Solution 0.2% twice a day OS on a consult report. The DON verified OS was an abbreviation for the left eye. The resident had a cyst on his right eye and LPN #107 thought this medication was supposed to be for the OD so she changed the MAR. The DON stated Resident #87 probably received the Brimonidine Tartrate Solution 0.2% eye drop medication to the wrong eye since 12/14/18. On 01/09/19 at 2:39 P.M. a telephone interview was conducted with LPN #107. LPN #107 said the resident went out for an eye appointment for a cyst to OD. The physician ordered Brimonidine Tartrate Solution 0.2% twice a day OS for glaucoma. The nurse reviewed the consult order and thought OS stood for the right eye so she changed the MAR to administer the eye drop medication to the right eye. The nurse was unaware that OS indicated the left eye. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure an as needed pain medication was not given in an excessive duration, without adequate monitoring and without indication for use. This affected one (#39) of five residents reviewed for unnecessary medications. The facility census was 95. Residents Affected - Few Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with the following diagnoses; acute cholecystitis, rheumatoid arthritis, hypothyroidism, hypertension, low back pain, gastro esophageal reflux disease, asthma, symbolic dysfunctions, type two diabetes mellitus, major depressive disorder and chronic obstructive pulmonary disease. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required limited assistance with transfers, and toileting. Resident #39 was also independent with bed mobility, dressing and eating and required supervision with personal hygiene. Resident #39 was listed as having frequent pain with no instances with pain interfering with her sleep or activities. Further review of Resident #39's record revealed the resident was discharged to the hospital on [DATE] for knee surgery. Resident was reported to readmit to the facility on [DATE]. Review of Resident #39's orders revealed the resident was ordered Percocet 5-325 milligrams (mg) one tablet for pain rated one to five and two tablets for pain rated six to ten on 09/20/18 following her knee surgery on 09/19/18. Resident #39's Percocet 5-325 mg one tablet for moderate pain and two tablets for severe pain was continued for seven days on 09/27/18. Review of Physician #502's progress note dated 10/01/18 revealed Resident #39 appeared comfortable with no complaints. Physician #502's progress note reported resident was on short term oxycodone for her knee replacement. Physician #502's progress note indicated medications were reviewed and orders were signed and written. Resident #39 was ordered to continue her Percocet 5-325 mg by mouth every four hours for pain for a pain rating more than seven on 10/04/18. Resident #39 was also ordered to follow up with Orthopedic Surgeon #500 in three weeks. Review of the physician to facility communication form dated 10/04/18 revealed Resident #39 followed up with Orthopedic Surgeon #500's office on this date and Resident #39's x-rays and incisions were good. Resident #39 was reported to follow up in six weeks. The form did not contain any information regarding Resident 39's medications. The form was signed by Orthopedic Surgeon #500. Resident was ordered Percocet 5-325 mg by mouth every four hours as needed for severe pain on 10/19/18. Resident #39's Percocet 5-325 mg was decreased to Percocet 5-325 mg by mouth every six hours as needed for pain on 11/01/18. Review of the physician to facility communication form dated 11/01/18 revealed Resident #39 followed up with Orthopedic Surgeon #500's office on this date and Resident #39's wound was healed. Resident #39 was reported to follow up in six weeks. The form did not contain any information regarding (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0757 Resident 39's medications. The form was signed by Orthopedic Surgeon #500. Level of Harm - Minimal harm or potential for actual harm Review of Physician #502's progress note dated 11/05/18 revealed Resident #39 to appear comfortable with no new complaints. Resident #39 reported that she felt her knee was improving during the assessment. Physician #502's progress note reported resident to be on short term oxycodone for her knee replacement. Physician #502's progress note stated medications were reviewed and orders were signed and written. Residents Affected - Few Review of Resident #39's progress notes from 12/01/18 to 01/10/19 revealed no documentation of pain or non-pharmaceutical interventions attempted with the resident prior to giving her as needed Percocet. Review of Resident #39's Medication Administration Report (MAR) from 12/01/18 to 12/31/18 revealed the resident obtained four doses of her Percocet Tablet 5-325 mg on 12/08/18, 12/10/18, 12/12/18, 12/14/18, 12/15/18, 12/22/18 and 12/26/18. Further review of the MAR from 12/01/18 to 12/31/18 revealed the resident received three doses of her Percocet on 12/01/18, 12/03/18, 12/04/18, 12/05/18, 12/06/18, 12/07/18, 12/11/18, 12/13/18, 12/17/18, 12/18/18, 12/19/18, 12/20/18, 12/21/18, 12/23/18, 12/24/18, 12/27/18, 12/28/18, 12/29/18 and 12/31/18. Resident #39 received two doses of her Percocet on 12/02/18, 12/09/18, 12/16/18, 12/25/18 and 12/30/18. Resident #39 did not have any days listed on the MAR where she received less than two doses of the Percocet. Review of Resident #39's pain flow administration record from 12/01/18 to 12/31/18 revealed there was no documentation of pain for the as needed pain medication, no documentation of non-pharmaceutical interventions completed and no documented outcome of Resident #39's as needed pain medication was listed on the pain flow administration record from 12/01/18 to 12/31/18. Review of Physician #502's progress note dated 12/03/18 revealed Resident #39 appeared comfortable with no new complaints. Physician #502's progress note reported resident was on short term oxycodone for her knee replacement. Physician #502's progress note indicated medications were reviewed and orders were signed and written. Review of Physician #502's progress note dated 01/07/19 revealed Resident #39 appeared comfortable with no complaints of increased pain. Physician #502's progress note reported resident was on short term oxycodone for her knee replacement. Physician #502's progress note indicated medications were reviewed and orders were signed and written. Review of Resident #39's MAR from 01/01/19 to 01/10/19 revealed the resident obtained all four doses of her Percocet on 01/02/19. Further review of the MAR from 01/01/19 to 01/10/19 revealed the resident received three doses of her Percocet on 01/01/19, 01/04/19, 01/05/19, 01/06/19, 01/07/19, 01/08/19 and 01/09/19. Resident #39 received two doses of her Percocet on 01/03/19. Resident #39 received one dose of her Percocet on 01/10/19. Resident #39 did not have any days listed on the MAR from 01/01/19 to 01/10/19 where she received less than one dose of her Percocet. Review of Resident #39's pain flow administration record from 01/01/19 to 01/10/19 revealed there to be no documentation of pain for as needed pain medication, no documentation of non-pharmaceutical interventions completed and no documented outcome of Resident #39's as needed pain medication to be listed on the pain flow administration record from 01/01/19 to 01/10/19. Interview with Resident #39 on 01/07/19 at 10:04 A.M. revealed the resident denied having pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #78 on 01/10/19 at 10:26 A.M. revealed Resident #39 had routine pain. LPN #78 stated Resident #39 received as needed pain medication for her pain. LPN #78 reported Resident #39 reported her pain to be a three out of 10 on this date and that she was given her as needed pain medication this morning. LPN #78 reported resident had severe pain at times. LPN #78 reported he would attempt to do imagery with Resident #39 but would provide her with the as needed pain medication if it was available. Follow up interview with Resident #39 on 01/10/19 at 10:28 A.M. reported she did not have any pain on this date. Resident reported she had a little bit of pain on 01/09/19. Resident #39 reported she received her pain medications on 01/09/19 but was not provided any other interventions for per pain on 01/09/19. Telephone interview with Nurse Practitioner (NP) #501 on 01/10/19 at 11:06 A.M. revealed NP #501 worked at Orthopedic Surgeon #500's office. NP #501 reported all patients of Orthopedic Surgeon #500 were taken off their post operation pain medication within three months of their surgery. NP #501 confirmed that Resident #39 had surgery on 09/19/18 and verified that Resident #39 should not have been receiving her Percocet after 12/19/18 per Orthopedic Surgeon #500's practice for the use of pain medication after surgery. NP #501 reported Resident #39 had not been seen in Orthopedic Surgeon #500's office since 11/01/18. NP #501 reported she spoke with Assistant Director of Nursing (ADON) #11 on 11/01/18 and informed the facility to start to wean Resident #39 off her as needed Percocet. Interview with the Director of Nursing (DON) on 01/10/19 at 11:10 A.M. revealed Resident #39 had knee surgery on 09/19/18. The DON reported Resident #39 had been prescribed Percocet Tablet since her follow up appointment with Orthopedic Surgeon #500 on 11/01/18. The DON reported Resident #39 had another follow up appointment with Orthopedic Surgeon #500 on 12/17/18 but she refused to go to the appointment. The DON confirmed Resident #39 was receiving her as needed Percocet on a daily basis from 12/01/18 to 01/10/18 with the medication being given four times in 24 hours on eight days, three times in 24 hours on 26 days, two times in 24 hours on five days and one time in 24 hours on one day. The DON confirmed Resident #39's pain flow administration record from 12/01/18 to 01/10/19 revealed there was no documentation of pain for as needed pain medication, no documentation of non-pharmaceutical interventions completed and no documented outcome of Resident #39's as needed pain medication to be listed on the pain flow administration records from 12/01/18 to 01/10/19. The DON also verified there was no documentation in the progress notes regarding Resident #39 having pain or non-pharmaceutical interventions attempted for Resident #39's pain. The DON verified Orthopedic Surgeon #500 was not contacted and notified that Resident #39 was being given her as needed Percocet daily from 12/01/18 to 01/10/18 with the medication being given multiple times per day. The DON also verified no one from the facility followed up with Orthopedic Surgeon #500's office regarding Resident #39's as needed pain medication after Resident #39 refused to go to her appointment on 12/17/18. Interview with ADON #11 on 01/10/19 at 2:10 P.M. revealed she spoke with Orthopedic Surgeon #500's office on 11/01/18. ADON #11 reported Orthopedic Surgeon #500's office had ordered the Percocet was reduced to Percocet Tablet 5-325 mg by mouth every 6 hours for severe pain. ADON #11 stated she felt Orthopedic Surgeon #500 was going to discontinue the Percocet at Resident #39's appointment on 12/17/18 but the resident refused to go to the appointment. ADON #11 reported Orthopedic Surgeon #500 was contacted by the facility on 01/10/19 and Resident #39's Percocet was discontinued on this date. Review of the facility's Pain Assessment and Management policy dated March 2015 revealed non-pharmacological interventions may be appropriate alone or in conjunction with medication. The policy also revealed the response to interventions, the underlying causes and adverse consequences of pain will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 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 0757 be assessed. The policy also stated prolonged unrelieved pain will be reported to the physician. 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: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of cleaning schedule and policy review, the facility failed to ensure food items were maintained in a manner to prevent and protect food against contamination and spoilage. This affected all residents residing in the facility. The facility census was 95. Findings include: Observation of the facility's kitchen on 01/07/19 at 9:15 A.M. revealed there was a plastic spoon and food debris on the floor of the walk-in freezer. The walk-in freezer also contained two unlabeled and undated breakfast casseroles that were located in disposable aluminum pans. Observation of the walk-in refrigerator revealed a plastic container of fruit that was not labeled or dated and a box of donuts that were not covered or dated. Interview with Dietary Manager #103 at the time of the observation verified the above findings. Dietary Manager #103 reported the walk-in freezer was swept on Mondays and Thursdays. Dietary Manager #103 reported the uncovered and undated donuts in the refrigerator were not from breakfast service on 01/07/19 and were previously used on 01/06/19. Interview with Assistant Director of Nursing (ADON) #11 on 01/09/19 at 11:30 A.M. revealed the facility does not have any residents that receive no food by mouth. Review of the undated kitchen cleaning schedule revealed the freezer will be swept one time per week. Review of the facility's Food Receiving and Storage policy dated October 2017 revealed food services and other designated staff will maintain clean food storage areas at all times. Further review of the policy revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 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 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Woods Healthcare Center. 2025 Wyoming Avenue Cincinnati, OH 45205 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of facility policy, the facility failed to follow principles of infection control when performing wound care. This affected one (#9) of two residents reviewed for wound care. The facility census was 95. Residents Affected - Few Findings include: Review of the medical record revealed Resident #9 was admitted on [DATE]. Diagnoses included diabetes mellitus with diabetic neuropathy, dysphagia, peripheral vascular disease, venous insufficiency, anemia, chronic kidney disease, and urinary incontinence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance to total dependence upon staff for activities of daily living (ADLs), was always incontinent of bowel and bladder, was at risk for pressure ulcers, and had moisture associated skin damage. Review of the current physician's orders revealed the resident had wound care orders for lidocaine viscous to coccyx/buttocks openings prior to dressing changes every day and night; silver sulfadiazine (SSD) (a topical antibacterial medication) to sacral area after cleaning with normal saline, cover with dry dressing every day shift for moisture associated skin damage (MASD), and Calmoseptine to buttocks and peri area every day and night shift for preventive measure. Observation of wound care on 01/09/19 at 10:01 A.M. revealed Registered Nurse (RN) #34 performed the ordered treatment to Resident #9's sacral area. RN #34 was observed to have a plastic trash bag tied to the treatment cart. RN #34 washed hands, removed the soiled dressing, placed it into the trash bag, removed gloves, and washed hands again before applying new, clean gloves. RN #34 applied the ordered SSD to the resident's wound and then used her gloved hands to widen the opening of the trash bag before discarding the contaminated items in it. RN #34 did not remove the gloves nor perform hand hygiene after handling the trash bag containing the soiled items. Using the gloved hands, RN #34 scooped the prepared Calmoseptine ointment from a medicine cup and applied it on the resident's open wound. At the time of the observation, RN #34 and the Director of Nursing (DON) verified RN #34's gloves were contaminated after handling the trash bag, and that RN #34 used contaminated gloves to apply the prescribed ointment to the resident's open wound. Review of the facility policy titled, Handwashing/Hand Hygiene dated 08/2015 revealed the facility considers hand hygiene the primary means to prevent the spread of infections, and that hand hygiene should be performed after handling used dressings and contaminated equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 14 of 14