Inspection·October 5, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility document titled Professionalism In-Service for Housekeeper #105 presented by Corporate Housekeeping Supervisor (CHS) #106 dated 10/02/23 revealed Housekeeper #105 had signed the document which defined unprofessional behavior as discourteous, racist, rude, uncouth communication. Employees were expected to communicate with residents in a respectful manner. Interview with CHS #106 on 10/03/23 at 12:26 P.M. confirmed Housekeeper #105 told her she usually called Resident #28 light skin and he would often respond by calling her dark and lovely. CHS #106 confirmed she gave Housekeeper #105 an in-service on professionalism on 10/02/23. Review of the facility policy titled Resident Rights revealed residents will be treated with dignity and respect. Staff will speak respectfully to residents. 2. Review of the medical record for Resident #81 revealed an admission date of 09/06/23 with diagnoses including atherosclerosis, cocaine use, hypertension (HTN), malignant neoplasm of the esophagus, dysphagia, and anemia. Review of the MDS assessment for Resident #81 dated 09/15/23, revealed the resident was cognitively intact and required supervision and set up help of one staff with ADLs. Review of the facility document titled Concern Form dated 09/18/23 for Resident #81, revealed the resident was upset that his clothing was marked with permanent marker and his last name showed through his lighter items of clothing. Further review of the concern form revealed the items would be replaced by the facility, but the resident expressed he wanted identical items, and the facility was unable to find the same items. Observation on 10/02/23 at 12:38 P.M. revealed Resident #81 had seven shirts hanging in his closet, and the resident's last name could be read through the clothing. Interview with Resident #81 on 10/02/23 at 12:38 P.M., confirmed the facility staff took his clothes down to the laundry and wrote his last name in each article of clothing using a black permanent marker. Resident #81 confirmed he was embarrassed to wear the seven lighter-colored shirts because his name showed through, and he thought it looked undignified. Interview with Laundry Supervisor (LS) #103 on 10/03/23 at 2:56 P.M., confirmed the laundry aides had written Resident #81's name on all of his clothing upon admission with a permanent marker and the name was visible on the lighter colored items. LS #103 confirmed he had heard Resident #81 was upset that his name showed through his clothing. Review of the facility policy titled Personal Clothing dated 06/2016 revealed all clothing must be labeled in a manner that is both practical and respects the dignity of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 2 of 25 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 10/05/2023 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents had appropriate bedding and mobility devices to accommodate resident needs. This affected one resident (#140) of 18 residents sampled. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #140 revealed an admission date of 09/29/23 with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute respiratory failure (ARF) with hypoxia. Review of the admission weight record for Resident #140 dated 09/29/23 revealed the resident weighed 350 pounds and was 71 inches tall. Review of an admission note for Resident #140 dated 09/29/23, revealed the resident had bilateral wounds to the lower extremities and his legs were wrapped. Review of a nurse progress note for Resident #140 dated 09/30/23, revealed the resident was up in a wheelchair, and he required assistance of two staff to transfer from bed to chair. Observation of Resident #140 on 10/02/23 at 9:50 A.M., revealed the resident was lying in bed with a standard sized mattress. The bed did not appear to be large enough to accommodate the resident's height and weight. There was a bariatric wheelchair without footrests in the resident's room. Interview with Resident #140 on 10/03/23 at 9:50 A.M. confirmed he was admitted on [DATE] from the hospital and he required a bariatric bed. Resident #140 confirmed the bed provided by the facility was too small and was very uncomfortable for him. Resident #140 confirmed the facility staff told him they had ordered a bariatric bed for him, but it hadn't arrived yet. Resident #140 confirmed he had wounds to both lower extremities and he wanted to be able to use the wheelchair for long distances such as going to the smoke area or the dining room, but the wheelchair didn't have footrests. Resident #140 confirmed he needed footrests when being pushed in the wheelchair due to his lower extremity wounds. Interview with Maintenance Director (MD) #69 on 10/03/23 at 2:51 P.M. confirmed Resident #140 was admitted on [DATE] and the facility did not have a bariatric bed available. MD #69 confirmed the facility ordered a bariatric bed for Resident #140 which had arrived in the afternoon of 10/03/23. MD #69 confirmed the facility had ordered footrests for Resident #140's wheelchair, but they had not arrived yet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 3 of 25 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 10/05/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy the facility failed to ensure residents had their advanced directives /code status noted in the medical record. This affected two residents (#28 and #21) of the four residents sampled for advanced directives. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the hospital note for Resident #28 dated 06/17/22 revealed resident's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of the care plan for Resident #28 dated 06/28/22 revealed the resident's code status was DNRCC. Interventions included the following: code status will be established at time of admission/readmission and will be reviewed quarterly and as needed, obtain copies of advanced directives from resident / resident representative to have on file, obtain medical provider order for code status, and obtain the state specific form regarding code status. Review of the physician orders for Resident #28 dated 12/02/22 revealed an order which indicated the resident's code status was Do Not Resuscitate (DNR.) There was no additional information included in the order regarding whether the resident was a DNRCC or DNRCC-Arrest. Observation of Resident #28's paper medical record on 10/02/23 at 1:55 P.M. revealed the record did not contain a copy of his advanced directives, or the state of Ohio DNR form signed by the physician to indicate whether residents was a DNRCC or DNRCC-Arrest. Interview on 10/02/23 at 1:55 P.M. with Licensed Practical Nurse (LPN) #115 confirmed Resident #28's electronic medical record indicated he was a DNR, but the record did not indicate if he was a DNRCC or DNRCC-Arrest. LPN #115 confirmed Resident #28's hard medical chart did not include a copy of his advanced directives, the state of Ohio DNR form signed by the physician to indicate whether residents was a DNRCC or DNRCC-Arrest. Interview on 10/02/23 at 2:38 P.M. with Social Worker (SW) #43 confirmed the facility could not locate the advanced directives and the state of Ohio form for Resident #28 but his hospital note dated 06/17/22 indicated the resident was a DNRCC-Arrest. SW #43 confirmed the facility needed to get clarification from the resident and the physician regarding resident's correct code status. 2. Review of the medical record for Resident #21 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: encephalopathy, rhabdomyolysis, pressure right heel, right hip, atrial fibrillation, disease, and schizoaffective disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 4 of 25 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 10/05/2023 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the code status documents dated 08/01/23 for Resident #21 and provided by Social Service Designee, (SSD) #43, revealed the document was signed on 08/01/23 by the physician and the code status was a DNRCC. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 13. Review of the care plan dated 09/11/23 for Resident #21, revealed there was a DNR code status and no further specific orders regarding the code status. Interventions included to be the code status to be reviewed quarterly and as needed and to obtain medical order for code status. Review of the physician orders dated 08/02/23 for Resident #21, revealed a code status order of DNR and no other specific direction for the code status. Interview on 10/05/23 at 2:30 P.M. with SSD #43 verified Resident #21's code status order did not have the complete code status needed for staff to reference during an emergency. The signed code status was not available in the electronic medical chart for staff reference. Review of the undated facility policy titled Advanced Directives revealed each resident should have an advanced directive; copies will be made and placed on the hard chart medical record as well as communicated to the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 5 of 25 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 10/05/2023 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 0583 Keep residents' personal and medical records private and confidential. 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 staff honored the residents' right to privacy by failing to knock prior to entering the resident's room and the resident's bathroom. This affected two residents (#09 and #140) of 18 residents sampled. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #09 revealed an admission date of 03/08/17 with a diagnosis of peripheral vascular disease (PVD), diabetes mellitus (DM), alcoholic cirrhosis of the liver, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #09 dated 08/16/23 revealed the resident was cognitively intact and required limited assistance of one staff with activities of daily living. Review of the medical record for Resident #140 revealed an admission date of 09/29/23 with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute respiratory failure (ARF) with hypoxia. Interview on 10/03/23 at 9:50 A.M. of Resident #140 confirmed staff did not always knock prior to entering his room especially if the door was open. Observation on 10/03/23 at 9:54 A.M. revealed State Tested Nursing Assistant (STNA) #17 entered Resident #140's room without knocking and walked to the other side of the room and retrieved a bag of linen off the nightstand of Resident #140's roommate who was not in the room. Surveyor was standing in the room interviewing Resident #140 when STNA #17 entered the room. The door to the room was open per the resident's preference. Surveyor questioned STNA #17 regarding why she didn't knock prior to entering, and STNA #17 walked back to the door and knocked on it. Then STNA #17 opened the door of Resident #140's bathroom without knocking. Resident #140's room shared a bathroom with the adjoining room which was Resident #09's room. Resident #09 had his pants down and was sitting on the commode when STNA #17 opened the bathroom door without knocking. STNA #17 shut the bathroom door without saying anything and then asked Resident #140 if she could get his weight later. Resident #140 said yes. STNA #17 then exited Resident #140's room. Interview on 10/03/23 at 10:00 A.M. of STNA #17 confirmed she did not knock prior to entering Resident #140's room and wait to be invited into the room nor did she knock prior to opening the bathroom door to Resident #140's room. STNA #17 confirmed Resident #09 was sitting on the commode with his pants down when she opened the bathroom door without knocking. Review of the facility policy titled Resident Rights undated revealed staff will knock before entering a resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 6 of 25 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 10/05/2023 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 on record review, observation, resident interview, and staff interview the facility failed to ensure resident room furnishings were in good repair and properly functional. This affected two residents (#18 and #06) of 18 residents sampled. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 09/06/23 with diagnoses including atherosclerotic, cocaine use, hypertension (HTN), malignant neoplasm of the esophagus, dysphagia, and anemia. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #81 dated 09/15/23 revealed the resident was cognitively intact and required supervision and set up help of one staff with activities of daily living (ADLs.) Observation of Resident #81's room on 10/03/23 at 12:41 P.M. revealed the resident's foot board was broken and had a jagged edge exposed approximately one foot in length. Resident #81's closet door had a hole in it which measured approximately three inches in diameter and the electrical outlet in the resident's bathroom was non-functional. Interview of Resident #81 on 10/03/23 at 12:41 P.M., confirmed the foot board was broken when he was admitted , and the hole was in the closet door upon admission. Resident #81 confirmed the electrical outlet had not been working since he was admitted , and he was unable to use his electric razor in the bathroom in front of the mirror. Observation of Resident #81's room on 10/03/23 at 1:28 P.M. with Maintenance Director (MD) #69, confirmed he had not received any recent work orders for Resident #81's room. MD #69 confirmed Resident #81's foot board had a jagged edge exposed and should be replaced. MD #69 confirmed the hole in Resident #81's closet door should be repaired. MD #69 confirmed Resident #81's outlet was nonfunctional and should be repaired. 2. Review of the medical record for Resident #06 revealed an admission date of 02/08/21 with a diagnosis of dementia without behavioral disturbance. Review of the MDS assessment for Resident #06 dated 07/12/23, revealed the resident was cognitively intact and required supervision with ADLs. Observation of Resident #06's room on 10/03/23 at 7:23 A.M. with Licensed Practical Nurse (LPN) #56, revealed the cover of resident's mattress was peeling and had multiple tears in it. Interview with Resident #06 on 10/03/23 at 7:23 A.M., confirmed she had the same mattress for years and it had multiple tears in the cover, and there was diffuse peeling observed to the surface of the mattress. Interview with LPN #56 on 10/03/23 at 7:24 A.M., confirmed Resident #06's mattress was peeling and probably should be replaced. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 7 of 25 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 10/05/2023 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 Interview with MD #69 on 10/03/23 at 2:51 P.M. confirmed Resident #06's mattress was in a state of disrepair and should be replaced. MD #69 confirmed he had not received any recent work orders regarding Resident #06's mattress. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 8 of 25 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 10/05/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, resident interview, review of the facility's Self-Reported Incidents (SRIs) and review of facility policy and documents the facility failed to ensure the facility's abuse policy was implemented when allegations of abuse were initiated by residents. This affected one resident (#28) of the one resident reviewed for abuse. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Observation on 10/02/23 at 9:49 A.M. revealed Housekeeper #105 passed by Resident #28's room and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M. confirmed Housekeeper #105 routinely addressed him in this manner, and he felt it was disrespectful. Resident #28 confirmed he usually responded to Housekeeper #105 in a joking manner and called her dark and lovely whenever she called him light skin. Resident #28 confirmed he had been dealing with people making comments about his skin color since childhood and he had just given up on trying to get people to stop talking to him this way. Resident #28 confirmed he wanted to be called by his first name or by mister followed by his surname and he did not want staff or anyone to make remarks about his skin color. Interview with Housekeeper #105 on 10/02/23 at 9:59 A.M. confirmed she had called out, Hey, light skin, to Resident #28 as she passed by his room. Housekeeper #105 confirmed she usually referred to Resident #28 in this manner, and she presumed it didn't bother him, because he would often respond by calling her dark and lovely. Interview with the Administrator on 10/02/23 at 10:10 A.M., confirmed she was not aware Housekeeper #105 referred to Resident #28 by anything other than his name. Administrator confirmed Resident #28 had not reported any concerns regarding Housekeeper #105. The surveyor relayed to the Administrator the observation of the interaction between Housekeeper #105 and Resident #28 and the interviews obtained both with resident and Housekeeper #105. The Administrator confirmed Housekeeper #105's conduct did not sound appropriate and she would address the concern immediately. Review of a facility document titled Professionalism In-Service for Housekeeper #105 and presented by Corporate Housekeeping Supervisor (CHS) #106 dated 10/02/23, revealed Housekeeper #105 signed the document which defined unprofessional behavior as discourteous, racist, rude, uncouth communication. Employees were expected to communicate with residents in a respectful manner. The document revealed no documented evidence Housekeeper #105 was suspended pending an abuse investigation. Observation of Housekeeper #105 on 10/03/23 at 7:10 A.M. revealed Housekeeper #105 was mopping the floor in an area accessible to residents. Interview with Housekeeper #105 at the same time confirmed she was not suspended during the abuse investigation for Resident #28. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 9 of 25 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 10/05/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Administrator on 10/03/23 at 12:16 P.M., confirmed she had spoken to Resident #28 on 10/02/23 in the afternoon about his interaction with Housekeeper #105 on the morning of 10/02/23. The Administrator confirmed Resident #28 told her Housekeeper #105 had called out to him in the hallway, Hey, light skin, on 10/02/23. The Administrator confirmed Resident #28 said he usually called Housekeeper #105 dark and lovely whenever she called him light skin, and that Housekeeper #105 frequently called him light skin. The Administrator confirmed Resident #28 told her he was okay with Housekeeper #105. The Administrator confirmed she did not speak directly with Housekeeper #105, but CHS #106 gave Housekeeper #106 an in-service on professionalism. Interview with CHS #106 on 10/03/23 at 12:26 P.M., confirmed Housekeeper #105 told her she usually called Resident #28 light skin and he would often respond by calling her dark and lovely. CHS #106 confirmed she gave Housekeeper #105 an in-service on professionalism on 10/02/23. CHS #106 also confirmed Housekeeper #105 was not suspended during the investigation of the abuse allegations. Review of the facility's SRI (239825) initiated on 10/03/23 at 3:09 P.M. and titled Verbal Abuse, revealed Resident #28 was upset by the interaction with Housekeeper #105 in the morning of 10/02/23. Further review of the SRI revealed upon initial interview on 10/02/23, the resident was not bothered by the interaction and the housekeeper was educated in professionalism. On 10/03/23 Resident #28 was re-interviewed and reported he was upset by the interaction with Housekeeper #105. Housekeeper #105 was interviewed and suspended pending an investigation. The SRI was still being investigated during the survey. Interview with the Administrator on 10/04/23 at 10:37 A.M., confirmed the Surveyor informed her of the interaction between Resident #28 and Housekeeper #105 which occurred on the morning of 10/02/23. The Administrator confirmed she did not interview Resident #28 regarding the interaction until the afternoon on 10/02/23 and at that time he told her he was okay with Housekeeper #105. The Administrator confirmed she returned to interview Resident #28 a second time in the afternoon of 10/03/23 and at that time he told the Administrator that he was upset by Housekeeper #105's conduct. The Administrator confirmed Housekeeper #105 was not suspended until 10/03/23 in the afternoon but the alleged verbal abuse occurred in the morning of 10/02/23. The Administrator confirmed Housekeeper #105 worked her entire shift on 10/02/23 and most of the day on 10/03/23 before being suspended as she was the Alleged Perpetrator (AP) in SRI (239825). The Administrator confirmed the facility's policy required for APs involved in abuse allegations to be suspended from working with residents during the course of the investigation to protect residents from possible further abuse. The Administrator confirmed the facility did not properly implement their abuse policy. Review of the undated facility policy titled Ohio Abuse, Neglect, and Misappropriation revealed the facility would put measures in place to prevent other abuse incidents from occurring during the course of an abuse investigation. In the event a staff member has been accused of possible abuse, the staff member will be interviewed by the Administrator and escorted immediately from the facility. The staff member will be suspended by the Executive Director or designee, pending the outcome of the investigation of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 10 of 25 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 10/05/2023 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, resident interview, review of facility's Self-Reported Incident (SRI) and review of facility policy and documents the facility failed to prevent further potential abuse while an abuse allegation investigation was in progress. This affected one resident (#28) of one resident reviewed for abuse. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) During a random observation on 10/02/23 at 9:49 A.M., revealed Housekeeper #105 passed by Resident #29's room and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M., confirmed Housekeeper #105 routinely addressed him in this manner, and he felt it was disrespectful. Resident #28 confirmed he usually responded to Housekeeper #105 in a joking manner and called her dark and lovely whenever she called him light skin. Resident #28 confirmed he had been dealing with people making comments about his skin color since childhood and he had just given up on trying to get people to stop talking to him this way. Resident #28 confirmed he wanted to be called by his first name or by mister followed by his surname and he did not want staff or anyone to make remarks about his skin color. Interview with Housekeeper #105 on 10/02/23 at 9:59 A.M. confirmed she had called out, Hey, light skin, to Resident #28 as she passed by his room. Housekeeper #105 confirmed she usually referred to Resident #28 in this manner, and she presumed it didn't bother him, because he would often respond by calling her dark and lovely. Interview with the Administrator on 10/02/23 at 10:10 A.M., confirmed she was not aware Housekeeper #105 referred to Resident #28 by anything other than his name. Administrator confirmed Resident #28 had not reported any concerns regarding Housekeeper #105. The surveyor relayed to the Administrator the observation of the interaction between Housekeeper #105 and Resident #28 and the interviews obtained both with resident and Housekeeper #105. The Administrator confirmed Housekeeper #105's conduct did not sound appropriate and she would address the concern immediately. Review of a facility document titled Professionalism In-Service for Housekeeper #105 and presented by Corporate Housekeeping Supervisor (CHS) #106 dated 10/02/23, revealed Housekeeper #105 signed the document which defined unprofessional behavior as discourteous, racist, rude, uncouth communication. Employees were expected to communicate with residents in a respectful manner. The document revealed no documented evidence Housekeeper #105 was suspended pending the outcome of the abuse investigation. Observation of Housekeeper #105 on 10/03/23 at 7:10 A.M. revealed Housekeeper #105 was mopping the floor in an area accessible to residents. Interview with Housekeeper #105 at the same time confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 11 of 25 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 10/05/2023 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 0610 she was not suspended during the abuse investigation for Resident #28. Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 10/03/23 at 12:16 P.M., confirmed she had spoken to Resident #28 on 10/02/23 in the afternoon about his interaction with Housekeeper #105 on the morning of 10/02/23. The Administrator confirmed Resident #28 told her Housekeeper #105 had called out to him in the hallway, Hey, light skin, on 10/02/23. The Administrator confirmed Resident #28 said he usually called Housekeeper #105 dark and lovely whenever she called him light skin, and that Housekeeper #105 frequently called him light skin. The Administrator confirmed Resident #28 told her he was okay with Housekeeper #105. The Administrator confirmed she did not speak directly with Housekeeper #105, but CHS #106 gave Housekeeper #106 an in-service on professionalism. Residents Affected - Few Interview with CHS #106 on 10/03/23 at 12:26 P.M., confirmed Housekeeper #105 told her she usually called Resident #28 light skin and he would often respond by calling her dark and lovely. CHS #106 confirmed she gave Housekeeper #105 an in-service on professionalism on 10/02/23. CHS #106 also confirmed Housekeeper #105 was not suspended during the investigation of the abuse allegations. Review of the facility's SRI (239825) initiated on 10/03/23 at 3:09 P.M. and titled Verbal Abuse, revealed Resident #28 was upset by the interaction with Housekeeper #105 in the morning of 10/02/23. Further review of the SRI revealed upon initial interview on 10/02/23, the resident was not bothered by the interaction and the housekeeper was educated in professionalism. On 10/03/23 Resident #28 was re-interviewed and reported he was upset by the interaction with Housekeeper #105. Housekeeper #105 was interviewed and suspended pending an investigation. The SRI was still being investigated during the survey. Interview with the Administrator on 10/04/23 at 10:37 A.M., confirmed the Surveyor informed her of the interaction between Resident #28 and Housekeeper #105 which occurred on the morning of 10/02/23. The Administrator confirmed she did not interview Resident #28 regarding the interaction until the afternoon on 10/02/23 and at that time he told her he was okay with Housekeeper #105. The Administrator confirmed she returned to interview Resident #28 a second time in the afternoon of 10/03/23 and at that time he told the Administrator that he was upset by Housekeeper #105's conduct. The Administrator confirmed Housekeeper #105 was not suspended until 10/03/23 in the afternoon but the alleged verbal abuse occurred in the morning of 10/02/23. The Administrator confirmed Housekeeper #105 worked her entire shift on 10/02/23 and most of the day on 10/03/23 before being suspended as she was the Alleged Perpetrator (AP) in SRI (239825). The Administrator noted APs involved in abuse allegations were to be suspended from working with residents during the course of the investigation to protect residents from possible further abuse. Review of the undated facility policy titled Ohio Abuse, Neglect, and Misappropriation revealed the facility would put measures in place to prevent other abuse incidents from occurring during the course of an abuse investigation. In the event a staff member has been accused of possible abuse, the staff member will be interviewed by the Administrator and escorted immediately from the facility. The staff member will be suspended by the Executive Director or designee, pending the outcome of the investigation of the incident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 12 of 25 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 10/05/2023 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** 3. Record review for former Resident #85 revealed the resident was admitted to the facility on [DATE] and discharged to hospital on [DATE]. Diagnoses included malignant neoplasm of lung, respiratory failure, bone cancer, malnutrition, atrial fibrillation, and osteoporosis. Review of the MDS assessment dated [DATE] for Resident #85, revealed the resident had impaired cognition evidenced by a BIMS score of 0. Interview with Social Service Designee, (SSD) #43 on 10/05/23 at 2:30 P.M. verified former Resident #85 was discharged to the hospital on [DATE] and the Ombudsman had not been contacted regarding discharge status. SSD #43 stated former Resident #85's discharge status should have been reported to the Ombudsman at the end of the month of August 2023. Based on record review and interviews, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected three residents (#36, #70, and #85) out of three residents reviewed for discharges. The facility census was 90. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/22/23. Diagnoses included congestive heart failure (CHF), bipolar disorder, generalized anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 08/17/23 for Resident #36, revealed the resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of the medical record for Resident #36, revealed the resident was sent to the hospital and admitted on [DATE] with no documented the Ombudsman was notified. Interview with the Administrator on 10/04/23 at 2:18 P.M., revealed notification to the Ombudsman had not been completed for Resident #36's discharge to the hospital. 2. Review of the medical record for Resident #70 revealed an admission date of 05/13/23. Diagnoses included acute respiratory failure with hypoxia, type two diabetes mellitus (DM II), tracheostomy, colostomy status, and hypertensive heart disease. Review of the MDS assessment dated [DATE] for Resident #70, revealed the resident had moderate cognitive impairment as evidenced by a BIMS score of 12. Review of the medical record for Resident #36, revealed the resident was sent out to the hospital and admitted on [DATE], 07/29/23, and 08/08/23 with no documented evidence the Ombudsman was notified. Interview with the Administrator on 10/04/23 at 2:18 P.M. revealed notification to the Ombudsman had not been completed for Resident #70's discharges to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 13 of 25 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 10/05/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and policy review, the facility failed to ensure residents' fingernails were timed and clean. This affected one resident (#239) of three residents reviewed for activities of daily living (ADLs). The facility census was 90. Residents Affected - Few Findings include: Review of the medical record for Resident #239 revealed an admission date of 08/01/23. Diagnoses included paranoid schizophrenia, type two diabetes mellitus (DM II), antisocial personality disorder, and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) assessment 3.0 dated 08/09/23 for Resident #239, revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require one-person extensive assistance with dressing, eating, toileting, personal hygiene, and bathing. Observation of Resident #239 on 10/02/23 at 3:40 P.M. revealed the resident was lying in bed. Resident #239's fingernails were observed to extend approximately a quarter of an inch to a half an inch beyond his fingertips and were yellow in color with jagged edges. Further observation revealed the underside of Resident #239's fingernails were coated in a dark brown substance. Interview with Resident #239 on 10/02/23 at 3:40 P.M. revealed he asked a staff member earlier to cut his nails and said she would be back, but she had not returned. Observation of Resident #239 on 10/03/23 at 3:10 P.M. revealed the resident's fingernails had still not been trimmed or cleaned. Interview with State Tested Nurse's Aide (STNA) #30 on 10/03/23 at 3:17 P.M. verified Resident #239's fingernails were long and jagged and needed to be cut and soaked. Review of the facility policy titled, Routine Resident Care, revealed the facility was to provide routine daily care by a certified nursing assistant with specialized training in rehabilitation/restorative care under the supervision of a licensed nurse including body position, adequate fluid, and nutritional intake, assisting with activities of daily living, and dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 14 of 25 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 10/05/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide pain management interventions in accordance with the resident's care plan. This resulted in Actual Harm to Resident #139 who had traumatic burn wounds to her bilateral lower extremities and was not medicated for pain prior to wound care which resulted in the resident exhibiting signs of severe pain. This affected one resident (#139) of three residents reviewed for pain management. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #139 revealed an admission date of 09/29/23 with diagnoses of cellulitis and open wounds of the lower legs. Review of an admission nursing progress note for Resident #139 dated 09/29/23, revealed the resident was alert and oriented and was able to make her needs known. Review of the care plan for Resident #139 dated 09/29/23, revealed the resident had complaints of acute/chronic pain and/or was at risk for pain. Interventions included the following: administer non-pharmacological interventions (repositioning, diversion activities, snacks and fluids, ice/heat, music therapy, relaxation techniques, imagery), complete a pain assessment on admission/re-admission, quarterly, significant change, and as needed, and follow the physician orders for complaint of pain. Review of the physician's orders for Resident #139 dated 09/29/23, revealed the resident was ordered to receive Tylenol 650 milligrams (mg) every six hours as needed (PRN) for pain. Resident #139 had no other pain medications ordered. Review of the physician's orders for Resident #139 dated 09/30/23, revealed the resident was ordered to have wounds to lower extremities cleansed with normal saline and patted dry, Santyl applied to wounds, Dakin's-soaked gauze applied, and wrapped with Kerlix gauze once daily. Review of the progress note for Resident #139 dated 10/03/23 and authored by nurse practitioner (NP) #104, revealed the resident had burn wounds to her lower legs related to a motorcycle accident. The left lower leg was a full thickness wound which measured 16 centimeters (cm) in length by 9 cm in width by 0.2 cm in depth. The wound contained slough tissue and had a scant amount of serosanguinous drainage. The right lower leg was a full thickness wound which measured 16 cm in length by 9 cm in width by 0.2 cm in depth. The wound contained slough tissue and had a scant amount of serosanguinous drainage. The resident's wound pain at rest was seven on a scale of one to 10 (zero being no pain and 10 being the worst pain.) NP #104 recommended the resident should receive pain medication prior to dressing changes as the wounds were quite tender with dressing removal. The primary provider should order and manage the pain medications. Observation of wound care on 10/03/23 at 12:55 P.M. per Registered Nurse (RN) #06 and NP #104 revealed as the nurse was removing the ace wrap covering the dressings to Resident #139's lower legs, she asked the resident if she was having any pain to her legs and the resident said the pain was a seven out of 10. Resident #139 confirmed she had not received any pain medication on 10/03/23. RN #06 told the resident she would try to be gentle. As RN #06 began removing the gauze from the old dressing it was stuck to the resident's skin and the resident cried out in pain and began cursing. The resident apologized for cursing but said when the nurse made contact with the wounds the pain increased (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 15 of 25 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 10/05/2023 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 0697 Level of Harm - Actual harm Residents Affected - Few to 10 out of 10 scale. As RN #06 continued the various steps in the dressing change such as cleansing the wound, applying Santyl, and applying the Dakin's gauze, the resident continued to curse and express extreme discomfort. NP #104 measured the resident's wounds after RN #06 removed the old dressings. Interview with RN #06 on 10/03/23 at 1:15 P.M., confirmed Resident #139 had not received any pain medication prior to the dressing change and the resident had Tylenol ordered for pain PRN. Interview with NP #104 on 10/03/23 at 1:17 P.M., confirmed this was the first time she had seen Resident #139's wounds, and she was going to recommend that resident receive pain medication prior to dressing changes and that the resident might need a stronger medication than Tylenol as the wounds were full thickness burn wounds, and resident showed signs of severe pain during the procedure. Interview with Resident #139 on 10/03/23 at 1:20 P.M., confirmed when she had her wound dressings changed in the hospital, they always gave her a pain pill before her dressing change to her legs and she did not know why they did not offer that in the facility. Resident #139 apologized again to the surveyor for cursing during the dressing change but said she could not help herself because it hurt so badly. Review of the October 2023 Medication Administration Record (MAR) for Resident #139 revealed the resident had not been administered any Tylenol on 10/03/23. Review of the undated facility policy titled Pain Management and Assessment revealed the facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the resident's comprehensive care plan, and the resident's choices, related to pain management. There was no objective test that could measure pain, and the clinician must accept the resident's report of pain. Factors such as activities, care, or treatment could precipitate or exacerbate pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 16 of 25 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 10/05/2023 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a timely physician response to the monthly pharmacist drug regimen reviews. This affected one resident (#28) of five residents reviewed for medications. The facility census was 90 residents. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the physician's orders dated 07/14/23 for Resident #28, revealed the resident was ordered to have the following laboratory (labs) tests drawn: complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), fasting lipids, and hemoglobin A1C. Review of the pharmacist's recommendations dated 08/03/23 for Resident #28, revealed the resident had a physician's order on 07/14/23 to have labs completed which included CBC, CMP, TSH, fasting lipids, and hemoglobin A1C, but the lab results were not in the chart and had not been addressed by the physician. The physician had not responded to the pharmacist's recommendations. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the pharmacist recommendations dated 09/05/23 for Resident #28, revealed this was a repeat recommendation from 08/03/23. The resident had a physician's order on 07/14/23 to have labs completed which included CBC, CMP, TSH, A1C and fasting lipids but the lab results were not in the chart and had not been addressed by the physician. The physician had not responded to the pharmacist's recommendation. Interview with Regional Nurse (RN) #116 on 10/03/23 at 3:50 P.M. confirmed the physician had not responded to the pharmacist's recommendations on 08/03/23 and 09/05/23. Review of the facility policy titled Medication Regimen Review dated 02/28/23 revealed the Consultant Pharmacist (CP) would conduct a monthly medication regimen review for each resident in the facility. Any medication irregularities noted by the CP during the monthly review would be documented in a separate written report. The Director of Nursing (DON)/designee would be responsible for addressing all medication irregularity reports with the attending physician or non-physician practitioner. The CP should review the reports with the DON each month. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 17 of 25 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 10/05/2023 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure laboratory (labs) tests were completed in a timely manner as ordered by the physician. This affected one resident (#28) of 18 residents sampled. The facility census was 90 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the physician's orders dated 07/14/23 for Resident #28, revealed the resident was ordered to have the following labs completed: complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), fasting lipids, and hemoglobin A1C. Review of the medical record for Resident #28 revealed the labs ordered by the physician on 07/14/23, CBC, CMP, TSH, fasting lipids, and hemoglobin A1C, were not obtained until 09/12/23. The record did not include a rationale for the delay in obtaining the labs as ordered by the physician. Interview with Regional Nurse (RN) #116 on 10/03/23 at 3:50 P.M. confirmed the labs ordered on 07/14/23 for Resident #28 were not completed until 09/12/23. RN #116 was unsure why the labs were not obtained in a timely manner. Review of the undated facility policy titled Laboratory and Radiological Services and Results Reporting revealed the facility was responsible for the timeliness of laboratory services ordered by the physician or practitioner regardless of whether the services are provided by the facility or by an outside source. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 18 of 25 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 10/05/2023 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on medical review, observation, resident interview, and staff interview, and review of the facility policy the facility failed to ensure residents received routine dental services. This affected one resident (#28) of 18 residents sampled. The facility census was 90. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the physician's order for Resident #28 dated 11/10/22, revealed the resident may have a dental consult. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Observation of Resident #28 on 10/02/23 at 9:55 A.M. revealed the resident had a chipped upper front tooth. Interview with Resident #28 on 10/02/23 at 9:55 A.M. confirmed he had a chipped upper front tooth which was not painful, but it bothered him, and he thought the tooth might need to be removed. Resident #28 confirmed he had not been offered an opportunity to see the dentist since his admission to the facility. Interview with Regional Nurse (RN) #116 on 10/03/23 at 3:50 P.M. confirmed Resident #28 had a physician's order which indicated he could have a dental consult, but the resident had not bee seen by a dentist since his admission to the facility. Review of undated facility policy Dental Servicesrevealed dental and oral health could impact the physical as well as the mental/emotional and psychological health of a resident. Poor dentition and/or poor oral health may impact nutritional and weight loss status. Routine dental services per the facility policy meant an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, and smoothing of broken teeth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 19 of 25 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 10/05/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observations, staff interviews, review of resident's diet lists, and review of facility policy, the facility failed to provide menus as planned by a Registered Dietitian (RD). This affected 13 Residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69, and #06) of the 13 residents observed in the main dining room. The facility also failed to provide appropriate substitutions to residents. This affected four residents (70, # 53, #38 and #07) of the four residents identified by the facility as receiving puree diets. The facility census was 90. Findings Include: 1. Observation of the initial dining service in the main dining room on 10/04/23 from 12:00 P.M. through 12:30 P.M. revealed all 13 residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) received a four ounce (one-half cup) serving of salad. Review of the menu spreadsheet dated 10/04/23 revealed residents on regular diet, 2-gram sodium diet, carbohydrate-controlled diet and dysphagia advanced diets were ordered to receive eight ounces (one cup) of salad during the lunch meal service. Review of a facility document titled Resident Diet Listing revealed residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) were listed as being ordered to receive eight ounces (one cup) of salad. Observation and interview on 10/04/23 at 12:30 P.M with Diet Manger, (DM) #55 verified the salad portion served to the 13 residents in the dining room was a four-ounce serving of salad and should have been an eight-ounce portion. The DM #55 stated the serving bowl used for the residents in the dining was a four-ounce bowl instead of an eight-ounce bowl. 2. Observation of the lunch tray line service on 10/04/23 from 12:00 P.M. through 12:30 P.M revealed residents (#70, # 53, #38 and #07) received pudding. The facility identified four residents (#70, # 53, #38 and #07) who were ordered to receive puree consistency diets. Review of the menu spreadsheet dated 10/04/23, revealed the four residents on puree diets should have received puree mandarin oranges. Review of the substitution log dated 10/04/23 revealed no entry of a substitution for puree mandarin oranges. Interview on 10/04/23 at 12:30 P.M. with DM #55, verified the residents with a puree order received pudding instead of the planned menu of puree mandarin oranges. DM #55 verified the mandarin oranges should have been prepared as per the puree mandarin orange recipe. DM #55 verified the puree mandarin orange recipe was not available for the cook to prepare. DM #55 stated the substitution had not been approved by the RD or recorded on the substitution log. Interview with RD #110 on 10/05/23 at 10:4 A.M., verified all meals are to be provided as listed on the menu and all substitutions were to be approved by the RD and must be listed on the substitution log. RD #110 verified she had not been contacted on 10/04/23 regarding a substitution of pudding for the mandarin oranges. RD #110 stated the puree mandarin oranges should have been prepared for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 20 of 25 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 10/05/2023 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 0803 residents receiving puree diets and stated the pudding was not a like substitution for mandarin oranges. Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled Menus revealed menus will be served as written, and the RD approves the menus. A substitution log would be maintained. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 21 of 25 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 10/05/2023 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation and staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 89 residents who received food from the kitchen. The facility census was 90. Findings include: 1. Observations of the kitchen on 10/02/23 from 9:05 A.M. through 12:30 P.M. revealed the following: a. There was a trash can under the preparation (prep) sink that had no lid and was full of food debris and trash. b. The 100-A, 100-B, 200-A, and 200-B unit meal delivery carts were noted to have a large buildup of brownish food debris in the corners and sticky substances on the interior cart racks where meal trays were being stored during delivery. During lunch meal service, staff were observed placing the resident's food tray in the dirty carts and the trays being delivered were observed touching the soiled areas of the food carts racks. c. Numerous ceiling tiles directly above the stove were soiled with brownish substances which appeared to be from splatters. d. Two air vents above the dish machine area where clean dishes had exited the dishwasher were noted to have a build-up of black fuzz around the vents and on the ceiling. e. There was a three-foot-long area of black, wet substance consistent with the appearance of mold along the dish machine dish rack table and the caulking seal was missing along the strip. f. There was a large build-up of brownish looking substance on the pipes and along the floor under the three- compartment sink. g. An unsecured electrical wire was hanging from the ceiling and identified by the kitchen staff as being the main electrical power source for the steam table had dark fuzzy substance on the cord and hanging from the cord. The electric cord was hanging directly over one side of the steam table where lunch was being served from. Interview with Dietary Manager (DM) #55 on 10/05/23 at 11:50 A.M., verified the observations of the kitchen on 10/02/23. The DM #55 stated the Cleaning Schedule form was to be completed by staff daily and once a week for areas of delivery carts cleaning, dishwasher area, floors, and sinks. The DM #55 was unable to show documentation of any cleaning records or when the kitchen areas were last cleaned. 2. Observation of the 200-unit refrigerator on 10/05/23 at 12:00 P.M. revealed a sign posted on the exterior part of the refrigerator which noted the refrigerator was only for the residents use and all resident foods were to be labeled and dated, and foods were to be discarded after seven days. Observation of the refrigerator included a container of food unlabeled and undated, unrecognizable food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 22 of 25 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 10/05/2023 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 - Some dated 09/27/23, food appeared to be some type of meat unlabeled and undated, two resident named foods undated, and an opened 64-ounce juice container undated and a pizza box containing pizza unlabeled and undated. Interview at the same time with Licensed Practical Nurse, (LPN) #33, verified the resident refrigerator was only to be used by residents and indicated all foods must be labeled and dated. LPN #33 verified the contents of the refrigerator. LPN #33 indicated the refrigerator was used for all 89 residents who received from the kitchen. Review of the undated facility policy titled Environment, the Dining Service Director will ensure the kitchen is maintained in a clean and sanitary manner including floors, ceilings, sanitizing equipment, and food contact surfaces. The Director will ensure a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. All trash will be contained in cover containers. Review of the undated facility policy titled Storage of Resident Food, revealed refrigerators will be monitored daily and containers will be dated, and food discarded when no longer safe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 23 of 25 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 10/05/2023 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to have the Medical Director in attendance at the Quality Assurance and Performance Improvement (QAPI) meetings. This had potential to affect all 90 residents who resided in the facility. Residents Affected - Many Findings include: Review of the QAPI quarterly meetings sign-in sheets dated 10/22/22, 01/15/23, 04/19/23 and 08/09/23, revealed no documented evidence the Medical Director attended the meetings. Interview with the Administrator on 10/05/23 at 2:32 P.M. verified the Medical Director did not attend the QAPI meetings on 10/22/22, 01/15/23, 04/19/23 and 08/09/23. The Administrator reported the Medical Director was required to attend all the QAPI Meetings as part of the required attendees. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 24 of 25 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 10/05/2023 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to maintain essential kitchen equipment in a safe and sanitary condition. This affected all 89 residents who received meals from the kitchen. The facility total census was 90. Residents Affected - Some Findings include: Observation of the kitchen on 10/04/23 at 12:00 P.M., revealed the steam table had electrical wires in three sections hanging two inches below the back covering. There was an on/off switch inside the lower cabinet and all four temperature control knobs were missing. The steam team table had a brownish, sticky substance covering most of the steam table. Continued observation revealed the renal diet ravioli appeared to be dry and sticking to the steam table pan. Interview with [NAME] #64 on 10/04/23 at 12:45 P.M. verified food dries out quickly on the steam table as the temperature knobs are not available to control the steam temperature. She verified the ravioli was dry and stuck to the pan, making it less palatable. Interview with the Diet Manager (DM) #55 on 10/04/23 at 12:50 P.M. verified the hanging wires should not be exposed and should be up under the steam table panel. The DM #55 stated the control knobs had been missing for years and an on/off switch was installed. The on/off switch had the steam table on high temperature at all times or turned off. There were no controls to permit warming of the food at various temperatures. The DM #55 verified the steam table had baked on, non-cleanable substance and it was so old, it could not be cleaned. There were no manufacture directions available to review the replacement of the control knobs or cleaning instructions. DM #55 indicated there was no facility policy for maintaining essential kitchen equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 25 of 25