Inspection·November 16, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a post fall evaluation/notification dated 10/24/23 at 7:30 A.M. and authored by Registered Nurse (RN)/Unit Manager (UM) #252, revealed the resident had a witnessed fall with no injuries. The resident was not transferred to the hospital, the physician and responsible party was notified and resident had no pain. Review of Fall Risk Observation Tool dated 10/24/23 at 3:37 P.M. for Resident #10, revealed the resident was a fall risk and required a total mechanical lift for all transfers due to unable to bear weight, unable to cooperate, limited in movement and heavy or obese. Review of an Interdisciplinary Team (IDT) note dated 10/24/23 at 3:41 P.M. authored by RN/UM #252, revealed Resident #10 had a witnessed fall on 10/24/23. Resident #10 was being provided care by CNA #246 when the resident was moved over too far causing CNA #246 to lower him to the floor in room. The root cause of the incident was poor judgement of surface area on mattress and the interventions included an Occupational Therapy (OT) assessment. Review of incident log dated 10/24/24 at 5:40 P.M., revealed Resident #10 had a fall and lowered to the ground by staff member. Review of the fall investigation revealed a document titled Telephone Interview 10/24/23 and authored by Director of Nursing (DON). The statement indicated Certified Nursing Assistant (CNA) #246 reported she was taking care of Resident #10 and during the morning rounds, she had to change the resident's sheets. CNA #246 reported that while the resident was on his left side (the resident's strong side), the resident started sliding out of the bed and onto the floor. CNA #246 reported she assisted the resident to the floor to prevent the resident from hitting his head. A second unknown STNA entered the room and CNA #246 left to get the nurse. CNA #246 reported after the nurse assessed the resident, the three staff members assisted the resident back in the bed. The investigation revealed no documented evidence of the resident's fall being thoroughly investigated and the appropriate interventions being implemented to prevent a similar incident. Review of the nurse's progress notes dated 10/26/23 at 2:04 P.M. for Resident #10, revealed the resident was noted with signs and symptoms of pain and swelling to the right knee. Resident #10 was assessed by Nurse Practitioner (NP) #501 and ordered an Xray of the resident's right knee and leg due to pain and swelling. Review of the nurse's progress notes on 10/27/23 at 6:50 P.M., revealed the x-ray revealed no acute fractures, dislocations were noted, and the surrounding soft tissues were normal, and results reviewed with physician. No new orders and resident's brother was updated. Interview on 11/07/23 at 4:01 P.M. with Nurse Practitioner (NP) #501 revealed she assessed Resident #10 on 10/26/23 which was two days after the fall. NP #501 stated the staff reported Resident #10 had low food intake and reports of pain in his right leg. NP #501 stated the right leg looked swollen and Resident #10 grimaced and pulled leg back when the right leg was touched. NP #501 stated the resident had an as needed (PRN) order for Tylenol (pain) in place and she ordered an order for an x-ray of the right knee. NP #501 confirmed she was not aware the staff failed to provide pain medication for Resident #10 at any time after his fall. Interview on 11/08/23 at 12:30 P.M. with the DON and Regional Clinical Nurse (RCN) #500 indicated Resident #10 had a witnessed fall and the facility determined the root cause analysis was poor judgement of the surface of the mattress while the staff was turning Resident #10. The DON and RCN #500 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated they were unable to say what this meant, and since RN/UM #252 wrote the root cause analysis, she could explain it better. The DON stated the facility does not get a statement from the on-duty nurses when a resident falls because the facility utilized the nurse's progress notes as the nurse's statement. The DON confirmed Resident #10's nursing progress notes revealed a third caregiver who assisted Resident #10 off the floor after the fall on 10/24/23, however the facility did not attempt to identify that staff member or obtain a witness statement from them. RCN #500 confirmed Resident #10 was dependent on two staff members for bed mobility and transfers. The DON verified CNA #246 was providing personal care to Resident #10 by herself when the resident fell out of his bed onto the floor on 10/24/23. Interview on 11/08/23 at 12:35 P.M. with the RN/UM # 252, revealed Resident #10's fall was due to poor judgement of the surface of the mattress while CNA #246 attempted to turn Resident #10 in the bed. RN/UM #252 stated CNA # 246 did not utilize the correct judgement of where Resident #10 was on the mattress during care, and this is why he rolled out of bed onto the floor. Interview on 11/08/23 at 8:01 A.M. with CNA# 246, revealed she provided personal care to Resident #10 and attempted to change his sheet on 10/24/23 when she rolled Resident #10 onto his weaker side, and he kept going and fell onto the floor. CNA #246 indicated she rolled the resident away from her and she was on the opposite side of the bed when Resident #10 fell onto the floor. CNA #246 confirmed she was the only staff member present during the incident. CNA#246 stated she got the nurse and another CNA, and they placed Resident #10 back into bed after lifting him from the floor. CNA #246 indicated the facility staff did not utilize a gait belt to get Resident #10 back into the bed. Review of the facility policy titled, Fall Prevention and Management, dated 06/01/22, revealed it is the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs. The policy stated fall prevention and management is the process of identifying risk factors that can minimize the potential for falls and also a process to manage resident's care if a fall occurs. Further review of the policy revealed an investigation should include witness statements by having staff write a statement. The policy stated the fall interventions should be added to the care plan. This deficiency represents non-compliance investigated under Complaint Numbers OH00148209. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of facility fall investigation, review of facility policy, the facility failed to timely and adequately address a resident's complaints of pain following a fall. This affected one (#10) out of three residents reviewed for pain. The facility census was 85. Residents Affected - Few Findings Include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia malignant neoplasm of rectum, diabetes mellitus, hypertension, aphasia, insomnia, and epilepsy. Review of the physician's orders dated 12/17/21 for Resident #10, revealed the resident was to be monitored for pain twice day (each shift) and Tylenol (pain relief) 650 milligrams (mgs) every four hours as needed (PRN) for pain. On 08/22/23, an order for the resident to be transferred via Hoyer lift for all transfers. On 10/26/23, an order for the resident to have an x-ray completed on his right knee and leg due to pain and swelling. Review of the plan of care dated updated on 06/05/23 for Resident #10, revealed the resident had a risk for falls related to hemiplegia, an activities of daily living (ADLs) self-care performance deficit and was dependent on staff for ADLs due to dementia, hemiplegia, and contractures and weakness on the right side. The resident was dependent on two or more staff members for bed mobility and transfers. The care plan updated on 07/26/22, revealed Resident #10 had acute and chronic pain related to hemiplegia. Interventions included complete pain assessment with significant change and PRN, provide medications per orders and monitor for signs and symptoms of side effects and evaluated the effectiveness of medication. Review of the most recent Minimum Data Set (MDS) assessment 3.0 dated 10/01/23 for Resident #10, revealed the resident had severely impaired cognition. The assessment revealed Resident #10 required extensive assistance of two staff members with bed mobility and transfers. Review of the nurse's progress notes dated 10/24/23 at 5:20 A.M. for Resident #10 and authored by Licensed Practical Nurse (LPN) #274, revealed the resident was being assisted up by staff when the staff pulled resident, and he rolled past the staff member and rolled onto the floor on his left side parallel to the bed. The resident was assessed with no injuries and was assisted back into bed by three staff members and with the use of a gait belt. A call was made to the physician to report the fall with no injuries. Review of the Situation Assessment Background Recommendation (SBAR) summary dated 10/24/23 at 5:55 A.M. for Resident #10 and authored by LPN #274, revealed resident had a change in condition related to a fall. The nursing recommendations indicated the resident should be a two-person transfer/assist. Review of the post fall evaluation/notification dated 10/24/23 at 7:30 A.M. and authored by Registered Nurse (RN)/Unit Manager (UM) #252 revealed the resident had a witnessed fall with no injuries. The resident was not transferred to the hospital, the physician and responsible party were notified, and resident had no pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 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 - Minimal harm or potential for actual harm Review of an Interdisciplinary Team (IDT) note dated 10/24/23 at 3:41 P.M. authored by RN/UM #252, revealed Resident #10 had a witnessed fall on 10/24/23. Resident #10 was being provided care by CNA#246 when the resident was moved over too far causing CNA #246 to lower him to the floor in room. The root cause of the incident was poor judgement of surface area on mattress and the interventions included an Occupational Therapy (OT) assessment. Residents Affected - Few Review of the incident log dated 10/24/24 at 5:40 P.M., revealed Resident #10 had a fall and lowered to the ground by staff member. Review of the fall investigation revealed a document titled Telephone Interview 10/24/23 from Certified Nursing Assistant (CNA) #246 and authored by Director of Nursing (DON). CNA #246 reported she was taking care of Resident #10 and during the morning rounds, she had to change the resident's sheets. CNA #246 reported that while the resident was on his left side (the resident's strong side), the resident started sliding out of the bed and onto the floor. CNA #246 reported she assisted the resident to the floor to prevent the resident from hitting his head. A second unknown STNA entered the room and CNA #246 left to get the nurse. CNA #246 reported after the nurse assessed the resident, the three staff members assisted the resident back in the bed. The investigation revealed no documented evidence of the resident's fall being thoroughly investigated and the appropriate interventions being implemented to prevent a similar incident. Review of the SBAR summary dated 10/26/23 at 2:27 P.M. for Resident #10 revealed the resident had a change in condition. The resident had decreased and/or unable to eat and /or drink adequate amounts of food or fluids and other change in conditions. The summary indicated the Nurse Practitioner (NP) was in the facility and assessed the resident. The resident was assessed to have pain and an x-ray of his right knee and leg was ordered. Review of the nurse's progress notes on 10/27/23 at 6:50 P.M. revealed the x-ray revealed no acute fractures, dislocations, and the surrounding soft tissues were normal, and results reviewed with physician. No new orders and resident's brother was updated. Interview on 11/07/23 at 4:01 P.M. with Nurse Practitioner (NP) #501 revealed she assessed Resident #10 on 10/26/23 which was two days after the fall. NP #501 stated the staff reported Resident #10 had low food intake and reports of pain in his right leg. NP #501 stated the resident's right leg was swollen and the resident grimaced and pulled his leg back when the right leg was touched. NP #501 stated the resident already had a PRN order for Tylenol in place and she ordered an order for an x-ray of the right knee. NP #501 confirmed she was not aware the staff failed to provide any pain medications to Resident #10 after his fall. Review of the October and November 2023 Medication Administration Records (MARs) for Resident #10, revealed no documented evidence the resident was administered any of his PRN ordered Tylenol when the resident complained of pain. Review of the October and November 2023 Treatment Administration Records (TARs) for Resident #10, revealed the monitoring of resident's pain was recorded each shift; however, there were no assessments of the resident's pain to include any non-pharmacological interventions completed, pain intensity, pain location, the duration of the pain, and any aggravating or alleviating factors. Interview on 11/07/23 at 12:37 P.M. with the Director of Nursing (DON) confirmed Resident #10 had a witnessed fall on 10/24/23 when a staff member rolled the resident out of bed and onto the floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few while performing personal care. The DON confirmed Resident #10 was recorded as having pain on 10/26/23 and Resident #10 did not receive any of his PRN pain medications. The DON stated the facility staff would have given Resident #10 pain medications if he had pain, however, Resident #10 did not have pain. The DON confirmed the nurse documented Resident #10 had signs and symptoms of pain on 10/26/23 two days after his fall. The DON stated that was because Resident #10's family visited on 10/26/23 and reported Resident #10 had pain. The DON indicated no one questioned the family regarding the reason they thought Resident #10 had pain and no staff assessed the resident for pain. The DON stated Resident #10 was assessed by the NP on 10/26/23 as having pain and swelling to his right leg and the NP ordered an x-ray. The DON indicated the nursing staff monitored Resident #10 for pain twice daily by looking for signs of pain such as grimacing and other non-verbal indicators due to Resident #10 being nonverbal. The DON verified there was no documented evidence that the resident's pain was assessed to include any non-pharmacological interventions completed, pain intensity, pain location, the duration, and aggravating or alleviating factors. Interview on 11/08/23 at 8:01 A.M. with CNA# 246, revealed she provided personal care to Resident #10 and attempted to change his sheet on 10/24/23 when she rolled Resident #10 onto his weaker side, and he kept going and fell onto the floor. CNA #246 indicated she rolled the resident away from her and she was on the opposite side of the bed when Resident #10 fell onto the floor. CNA #246 confirmed she was the only staff member present during the incident. CNA#246 stated she got the nurse and another CNA, and they placed Resident #10 back into bed after lifting him from the floor. CNA #246 indicated the facility staff did not utilize a gait belt to get Resident #10 back into the bed. Review of the facility policy titled, Pain Management Assessment, undated, revealed it was the policy of the facility to provide resident centered care that meets psychosocial, physical, and emotional needs of the residents. Further review of the policy revealed the clinician must accept the resident's report of pain. Review of the facility policy titled, Fall Prevention Management, dated 06/01/22, revealed the facility manages a Residents care after a fall. The policy stated after a Resident has a fall, the resident should be assessed for pain. This deficiency represents non-compliance investigated under Complaint Number OH00147503 and is an example of continued noncompliance from the survey dated 10/05/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365455 If continuation sheet Page 6 of 6