Inspection·February 20, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm 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. Based upon record review, staff interview, and review of facility policy, the facility failed to accurately document the code status for one (Resident #56) of 18 residents sampled. The census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #56 revealed an admission date of 01/09/20. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, cerebral palsy, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/05/20, revealed Resident #56 was cognitively impaired. Review of the medical record for Resident #56 revealed a form signed by the resident's attending physician indicating resident's code status was Do Not Resuscitate Comfort Care (DNRCC)-Arrest. Review of dashboard of the electronic medical record (EMR) for Resident #56 revealed resident's code status was listed as DNRCC. Review of the current physician orders in the EMR for Resident #56 revealed resident's code status was listed as DNRCC. Interview on 02/19/20 at 9:15 A.M. with Registered Nurse (RN) #22 confirmed Resident #56's correct code status was DNRCC Arrest, and the dashboard of the EMR and the current physician orders did not reflect the resident's correct code status. RN #22 further confirmed the dashboard of the EMR, the current physician orders, and any signed DNR forms in the paper chart should all match to prevent confusion in an emergency. Review of facility policy titled Advance Directives/Care Planning, dated December 2016, revealed the facility would communicate resident preferences regarding advanced directives including code status to the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 2 of 15 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 02/20/2020 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 upon record review, observation, resident interview, and staff interview, the facility failed to maintain a homelike environment by storing wheelchairs and geri chairs in the room of one (#5) of 18 residents sampled. The census was 78. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/12/18. Diagnoses included hemiplegia and vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #5 dated 02/05/20 revealed resident was cognitively impaired, required extensive assistance with activities of daily living, and used a wheelchair for mobility. Observation on 02/18/20 at 10:00 A.M. of Resident #5's room revealed two wheelchairs in the room to the left of his bed and a geri chair in front of the bathroom door. Observation on 02/18/20 at 12:57 P.M. of Resident #5's room revealed two wheelchairs in the room to the left of his bed and a geri chair in front of the bathroom door. Interview on 02/18/20 at 12:59 P.M. with Resident #5 confirmed one of the two wheelchairs in his room belonged to him, but the other wheelchair and the geri chair were not his and they had been in his room all day. Interview on 02/18/20 at 1:02 P.M. with State Tested Nursing Assistant (STNA) #66 confirmed one of the wheelchairs in Resident #5's room belonged to another resident who resided across the hall and the geri chair was not assigned to a specific resident. STNA #66 further confirmed the wheelchair and geri chair were stored in Resident #5's room for staff convenience. Observation on 02/19/20 at 8:00 A.M. of Resident #5's room revealed two wheelchairs to the left of his bed. Interview on 02/19/20 at 8:05 A.M. with Licensed Practical Nurse (LPN) #71 confirmed one of the wheelchairs in Resident #5's room belonged to another resident who resided across the hall. LPN #71 further confirmed the extra wheelchair was stored in Resident #5's room because he did not have a roommate and had more space in his room for storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 3 of 15 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 02/20/2020 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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, resident interview, and staff interview, the facility failed to ensure a Wander Guard restraining device was not used in the absence of wandering behaviors for one (#45) of two residents reviewed for restraints. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included altered mental status, legionella pneumonia, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, hypertension, and anemia, Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/12/2020, revealed Resident #45 was cognitively intact. The resident required supervision and set up only for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #45 was independent in eating and required supervision only for toileting. Review of the elopement risk assessment, dated 06/29/19, identified Resident #45 as a low risk for wandering due to independent ambulation and taking antipsychotics. Review of the physician orders dated 07/01/19 revealed a order for a Wander Guard bracelet to the left ankle , check function and placement each shift. Review of the elopement risk/wanderer care plan, initiated 07/09/2019 and revised 02/12/2020, revealed a goal for Resident #45 to not leave the facility unattended. Interventions included to monitor for exit seeking behavior and apply Wander Guard to the left ankle. Review of the elopement risk assessment, dated 08/09/2019, identified Resident #45 to be a moderate risk for elopement. Risk were identified due to recent changes in room, medication change, surgery, caregiver or staff change and readmission within the last month. Review of the elopement risk assessment, dated 09/28/19, identified Resident #45 as being a low risk for wandering and taking antipsychotic. Review of the elopement risk assessment, dated 02/19/202, identified Resident #45 as being a moderate risk for elopement due to independent mobility, early dementia and taking antipsychotics. Review of the medical record from 06/29/19 though 02/20/20 did not identify any exit seeking behaviors. Interview on 02/18/2020 at 10:00 A.M., Resident #45 voiced she felt like she was in jail. She stated she had to wear a bracelet on her leg. She came here after having pneumonia and being weak. She needed therapy upon admission and can now care for herself. She did not know why she had to wear the Wander Guard bracelet as she said she was not going to runaway. She had no where to go since she no longer had her apartment. Observation on 02/18/2020 at 10:00 A.M. revealed Resident #45 to have a Wander Guard bracelet to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 4 of 15 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 02/20/2020 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 0604 the left ankle. Level of Harm - Minimal harm or potential for actual harm Interview on 02/20/2020 at 9:30 A.M., Licensed Practical Nurse (LPN) # 31 revealed she has cared for Resident #45 since her admission to the facility. She has never seen Resident #45 try to exit the the building. She use to wander frequently in the halls, walk up to the exit door, look outside, and then walk away. She did not try to open the door and she has not done this in a while. Residents Affected - Few Interview on 02/20/2020 at 9:46 A.M., with State Tested Nurse Aide (STNA) #78 revealed she has not seen Resident #45 open the exit doors. When her ex-husband and sons come to visit she will walk them to the door. Watch them leave and then she returns to her room or the dining area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 5 of 15 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 02/20/2020 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based upon record review, observation, and staff interview, the facility failed to accurately code the presence of side rail usage on the bed of one (#38) of two residents reviewed for restraints. The census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of hospice admission orders dated 09/12/19, revealed Resident #36 was admitted to hospice with a diagnosis of end stage Alzheimer's disease and an order for the hospice company to provide a bed with bilateral half side rails for the resident. Review of the Minimum Data Set (MDS) assessment, dated 12/17/19, revealed Resident #36 was cognitively impaired and required extensive assistance of two staff with bed mobility. Section P for the presence of side rails was coded as not used. Observation on 02/18/20 at 1:07 P.M. of Resident #36's bed revealed it had bilateral half side rails to the upper half of his bed. The bed had a sticker to the frame indicating it was the property of the hospice company. Interview on 02/19/20 at 12:30 P.M. with Licensed Practical Nurse #71 and Hospice Registered Nurse (RN) #127 confirmed resident was provided a new bed with bilateral half side rails on 09/12/19 upon his admission to hospice, and it had been in place since that time. Interview on 02/19/20 at 2:30 P.M. with the Director of Nursing (DON) confirmed Resident #38 had bilateral side rails to his bed since 09/12/19 and the MDS for dated 12/17/19 was coded inaccurately regarding the presence of side rails to the resident's bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 6 of 15 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 02/20/2020 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 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to develop a plan to reflect the discharge goals for one (#45) of two residents reviewed for discharge. The facility census was 78. Residents Affected - Few Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included altered mental status, legionella pneumonia, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, hypertension, and anemia, Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/12/2020, revealed Resident #45 was cognitively intact. The resident required supervision and set up only for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #45 was independent in eating and required supervision only for toileting. Under section Q0500B does the resident desire to talk to someone about the possibility of leaving the facility and returning to the community to live it was coded Yes. Q0500B was also coded Yes on prior MDS assessments completed on 07/06/19, 10/01/19 and 01/01/20. Review of the hospital Social Workers documentation, dated 06/26/2019, revealed Resident #45 only needed less then a 30 day convalescent stay in a skilled nursing facility. Review of the discharge care plan, initiated 07/01/2019 and revised on 02/12/20, revealed Resident #45 was appropriate for long term care due to Resident #45 was unable to care for herself in the community due to failure to thrive. Interventions included monitor care needs, report any changes the the physician and Social Services to support the resident and family in desires to remain in the facility. Review of 12/17/19 psychiatrist documentation revealed Resident #45 was alert, pleasant, engaging and calm. No agitation was noted. She was much more organized in her thoughts. She denied hallucinations and was doing well on current regimen. Review of the Administrator's documentation, dated 01/14/2020, revealed the resident expressed wishes to be able to return to the community, but at this time the resident needs a legal guardian and there were no plans for the resident to return to the community until after guardianship hearing. Review of the 02/18/2020 psychiatrist documentation revealed Resident #45 was alert, oriented to three spheres, and pleasant with no agitation or restlessness. Her speech was clear and logical. She reported no hallucinations or delusional thoughts. She was preoccupied with wanting to live on her own and wants to start living in assisted living. She informed the psychiatrist she had contacted the Ombudsman but has not heard anything. Interview on 02/18/2020 at 10:00 AM. Resident #45 shared she had became ill in June 2019 which required her to be admitted to the hospital for pneumonia. After receiving treatment in the hospital for the pneumonia it was decided she needed to go to a nursing home to get stronger. She never agreed to stay here permanently. Before going in the hospital she lived in her own apartment, shopped for groceries herself and did her own banking. She stated she just wants her life back. On 01/27/2020 a meeting was held which the Ombudsman attended, as well as facility staff. In the meeting she told them (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 7 of 15 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 02/20/2020 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 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete she wanted to go back to her apartment. It was decided during the meeting she should go to an assisted living facility instead. She is agreeable to an assisted living. Since the meeting no one has spoken to her about moving to a assisted living facility. Interview on 02/18/2020 at 2:00 P.M., the Administrator revealed the facility was aware of Resident #45 wanting to return to the community but the facility has not planned for the residents return to the community. Event ID: Facility ID: 365455 If continuation sheet Page 8 of 15 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 02/20/2020 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to assess the need for the use of bilateral half side rails on the bed of one (Resident #38) of two residents reviewed for restraints. The census was 78. Findings include: Review of the medical record for Resident #38 revealed and admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of side rail assessment for Resident #38 dated 01/16/19 revealed resident did not use side rails and resident had not expressed a desire to have side rails on his bed. Review of hospice admission orders for Resident #38 dated 09/12/19 revealed the resident was admitted to hospice with a diagnosis of end stage Alzheimer's disease and an order for the hospice company to provide a bed with bilateral half side rails for the resident. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 12/17/19 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility. The MDS failed to code the presence of the side rails in Section P. Review of the physician orders for Resident #38 dated 01/28/20 revealed an order for resident to have bilateral half side rails to his bed to assist with bed mobility and to check placement every shift. Review of the care plan for Resident #38, updated 02/13/20, revealed the resident had a self-care deficit which fluctuated related to Alzheimer's dementia, generalized weakness, spinal stenosis, and confusion at times. Interventions included resident could have bilateral half side rails to assist with bed mobility. The record contained no assessment indicating the need for the use of the bilateral half side rails. Observation on 02/18/20 at 1:07 P.M. of Resident #38's bed revealed it had bilateral half side rails to the upper half of the bed, and the bed had a sticker to the frame indicating it was the property of the hospice company. Interview on 02/18/20 at 1:07 P.M. with Resident #38 confirmed the bilateral half side rails had been on his bed since sometime in 2019 and he did not use them, nor did he have a preference regarding their presence on his bed. Interview on 02/19/20 at 12:30 P.M. with Licensed Practical Nurse #71 and Hospice Registered Nurse (RN) #127 confirmed Resident #38 was provided a new bed with bilateral half side rails on 09/12/19 upon his admission to hospice and it had been in place since that time. Interview on 02/19/20 at 2:30 P.M. with the Director of Nursing (DON) confirmed Resident #38 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 9 of 15 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 02/20/2020 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bilateral side rails to his bed since 09/12/19 and facility had not completed an assessment of the appropriateness of side rails prior to their implementation nor had the facility assessed Resident #38 for the use of side rails since that time. Review of facility policy titled Bed Safety, dated December 2007, revealed prior to the use of side rails there would be an interdisciplinary assessment of the resident and side rails would be used only as needed to manage a medical symptom or condition or to help a resident reposition in bed and no other reasonable alternative could be identified. Further review of policy revealed before using side rails the staff would inform the resident and resident's representative of the potential hazards associated with side rails. Event ID: Facility ID: 365455 If continuation sheet Page 10 of 15 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 02/20/2020 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on record review, staff interview, and review of the facility policy, the facility failed to attempt gradual dose reduction (GDR) or document clinical contraindications to GDR for an antipsychotic medication, and failed to document behaviors necessitating the need for the use of an antipsychotic medication for one (Resident #5) of six residents reviewed for unnecessary medications. The census was 78. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/12/18 with a diagnosis of vascular dementia with behavioral disturbance. Review of the physician orders for Resident #5 revealed an order dated 07/06/18 for the antipsychotic Seroquel 25 milligrams (mg) to be administered twice daily for treatment of vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessments dated 02/15/19, 05/21/19, 08/12/19, 11/06/19, and 02/05/20 revealed Resident #5 was cognitively impaired, had received an antipsychotic medication for seven days during the reference period, no dosage reduction of the antipsychotic had been attempted, and the physician had not documented a dosage reduction as clinically contraindicated. Review of the Medication Administration Record (MAR) for Resident #5 for February 2019 through February 2020 revealed the resident received routine Seroquel twice a day during this time frame with no attempted dosage reduction. Further review of the MARs revealed they did not include tracking of resident behaviors or documentation of non-pharmacological interventions offered. Review of the care plan for Resident #5 dated 02/05/20 revealed resident was at risk for side effects related to antipsychotic medication use. Interventions included the following: monitor and record the occurrence of target behavior symptoms (agitation and resistance to care), consult with pharmacy and physician to consider dosage reduction when clinically appropriate at least once quarterly, discuss with resident, family and physician the ongoing need for the medication, monitor and record potential side effects related to medication including unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS) such as (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, review behavioral interventions and alternate therapies attempted and evaluate their effectiveness. Review of the nurse progress notes for Resident #5 dated 12/01/19 through 02/21/20 revealed notes were silent regarding resident behavioral symptoms. Review of outpatient psychiatrist note for Resident #5 dated 02/05/19 revealed the facility reported the resident's behaviors were stable and seemed to have intermittent agitation and combativeness due to dementia but none requiring pharmacologic intervention. Review of the consultant pharmacist report dated 06/14/19 revealed the pharmacist recommendation in which Resident #5 had received Seroquel 25 mg twice daily since 07/06/18 and a dosage reduction (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 11 of 15 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 02/20/2020 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be considered to determine the minimal effective dose. Further review of the report revealed the report had not been signed or addressed by the physician. The nurse had written on 07/01/19 she spoke with outpatient psychiatrist on the phone who indicated resident had been seen on 06/14/19 and the resident's dose of Seroquel was appropriate. Review of the outpatient psychiatrist note for Resident #5 dated 06/14/19 revealed resident was stable and had intermittent episodes of agitation with none requiring pharmacologic intervention. Review of outpatient psychiatrist note for Resident #5 dated 08/21/19 revealed the facility reported Resident #5 had not exhibited aggressive behaviors in months and facility should use behavioral interventions and redirection to assist with managing behaviors. Interview on 02/21/20 at 11:00 A.M. with the Director of Nursing (DON) confirmed a dosage reduction of Resident #5's Seroquel had not been attempted since it was ordered 07/06/18 nor had it been documented as clinically contraindicated. DON further confirmed Resident #5's record did not include tracking of target behaviors or documentation of non-pharmacological measures attempted to manage resident behavior. Review of the facility policy titled Antipsychotic Medications, dated December 2016, revealed antipsychotic medications would be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms had been identified and addressed. Further review of the policy revealed antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period of time and would be subject to gradual dose reduction and re-review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 12 of 15 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 02/20/2020 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, and review of facility policy, the facility failed to ensure food was stored and prepared in a clean environment, failed to ensure food items were dated and labeled as to the day they were opened, and failed to discard expired food items. This involved all 78 residents in the facility who received food from the kitchen. Findings include: 1. Observation on 02/18/20 at 8:40 A.M. during the initial tour of the kitchen with [NAME] #93 revealed [NAME] #93 was standing at the prep table with a cell phone in her hand which she placed in her pocket when surveyor entered the kitchen. A cell phone was sitting on the corner of the prep table. The dry storage had a plastic bag of hamburger buns with no expiration date which had been ripped open exposing the buns to air. The dry storage had an open jug of liquid butter and an open jug of hot sauce which had not been dated upon opening. The walk-in refrigerator had two pitchers of orange juice, one pitcher of milk, one pitcher of fruit punch, two pitchers of apple juice, none of which were dated or labeled. The walk-in refrigerator had a large bag of shredded cheese which had been ripped open exposing the cheese to air. The walk-in refrigerator had two plastic bags of shredded cabbage, one with an expiration date of 02/15/20 and one with an expiration date of 02/08/20, four containers of yogurt with an expiration date of 02/15/20, and two large packages of ground beef with an expiration date of 02/17/20. The walk-in freezer had a plastic bag of unlabeled and undated breaded fish filets which did not include an expiration date. The walk-in freezer had a plastic bag of unlabeled and undated ribs which did not include an expiration date. The walk-in freezer had a plastic bag of unlabeled and undated cinnamon sticks which did not include an expiration date with the bag ripped exposing the food to air. Interview on 02/18/20 at 8:40 A.M. with [NAME] #93 confirmed cell phones should not to be used in the food preparation area. Interview on 02/18/20 at 8:41 A.M. with Dietary Aide #57 confirmed the cell phone on the prep table was hers and cell phone should not be in the food preparation area. Interview on 02/18/20 at 9:00 A.M. with [NAME] #93 confirmed all the concerns observed during the initial kitchen tour. [NAME] #93 further confirmed all food containers should be labeled to indicate the contents, large containers of food should be dated upon opening, food should be stored in a manner to prevent exposure to air, and expired food should be discarded. Review of facility policy titled Food Receiving and Storage, dated 10/2017, revealed all foods stored in the refrigerator and freezer would be covered, labeled and dated with a use by date. Further review of the policy revealed dry foods would be labeled and dated with a use by date. Review of policy titled Cellular Telephones undated revealed cell phones are prohibited in resident care areas. 2. Observation on 02/19/20 at 11:30 A.M. revealed a metal, two shelf table at the end of the steam table with a bent second shelf. The shelf was rusted. Sitting on the shelf were six large plastic containers holding various condiments. Under the two compartment sink was a fan with the blades and grill soiled with dirt and dust. On top of a metal shelf near the dishwasher was a fan with soiled and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 13 of 15 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 02/20/2020 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 dusty blades and grill. A metal rack, containing 18 cookie sheets was observed to have a large amount of dried baked on food and grease. The range had dried greasy food splatters on the front and top of it. The outside of the two ovens doors had a dried greasy food splatters. The toaster was observed to have a brown greasy build up on the exterior and interior surface. Residents Affected - Many Interview on 02/19/20 at 11:30 A.M. the Dietary Manager was present and verified the observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 14 of 15 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 02/20/2020 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 Based on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure respiratory equipment was cleaned for one (Resident #38) of two residents reviewed for respiratory care. The census was 78. Residents Affected - Few Findings include: Review of the medical record for Resident #38 revealed and admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 12/17/19, revealed Resident #38 was cognitively impaired and required extensive assistance of two staff with activities of daily living. Review of the physician orders for Resident #38 revealed an order dated 01/21/19 for resident to have a continuous positive airway pressure (CPAP) applied every night. Review of physician orders for Resident #38 revealed an order dated 02/19/20 for resident's CPAP tubing mask to be cleaned every week on Wednesday. Review of Medication Administration Record (MAR) for January 2020 and February 2020 revealed there was no documentation of cleaning of resident's CPAP mask until 02/19/20. Observation on 02/18/20 at 1:07 P.M. revealed CPAP mask was dirty and had debris inside of it. Interview on 02/18/20 at 1:07 P.M. with Resident #38 confirmed he was not sure when and if his CPAP mask was cleaned. Interview on 02/18/20 at 1:09 P.M. with Licensed Practical Nurse (LPN) #42 confirmed Resident #38's CPAP mask was dirty, and she was unsure when it had been cleaned last. Interview with the Director of Nursing (DON) on 02/19/20 at 12:45 P.M. confirmed Resident #38 did not have order for cleaning his CPAP until 02/19/20 and CPAP masks should be cleaned weekly and as needed. Review of the facility policy titled CPAP Support, dated March 2015, revealed CPAP devices should be cleaned once weekly and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 15 of 15