Health inspection·December 31, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review revealed the facility failed to ensure each resident receives adequate supervision to prevent accidents. This affected one Resident (#5) out of 5 residents reviewed for accidents. The facility also failed to document or implement immediate interventions for falls. This affected one Resident (#33) out of 5 residents reviewed for accidents. The facility census was 33.1. Medical record review for Resident #33 revealed she was admitted to the facility on [DATE]. Her diagnoses included myelodysplastic syndrome, psychotic disorder with delusions due to known physiological condition, anemia, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively impaired. Resident #33 was dependent on staff for medication administration, bathing, lower body dressing, putting on shoes, and toilet use. Resident #33 required set up assistance with meals, and oral hygiene. She required maximum assistance from staff with upper body dressing. Review of the fall assessment dated [DATE] for Resident #33 revealed she scored a thirteen and this made her a moderate risk for falls. Review of the progress notes for Resident #33 revealed she had a fall on 12/24/25 at 5:41 P.M. Resident #33 was found on the floor, lying sideways off the bed with legs on the floor mat. The bed was in the lowest position. Resident #33 sustained two skin tears one on hand and one on the index finger. No immediate intervention was listed. Resident #33 was found on the floor on 12/24/25 at 7:45 A.M. She was found on the her left side with her head under the bed. Resident sustained a skin tear to her right lower leg and sustained a bruise to her left back. Resident #33 also sustained a bruise to the left side of her head. No immediate intervention was listed for the fall. Resident #33 had a fall on 10/11/25 at 5:38 P.M. Resident #33 was found on the floor and sustained a skin tear on the side of her left leg. No immediate intervention was listed. Review of fall investigation summary dated 12/14/25 at 7:45 A.M. revealed Resident #33 was observed on the floor mat in her room with her head under the bed. Resident sustained a right lower leg, left side of the back and bruising to the left side of the head. No immediate intervention was identified. Review of the follow up intervention revealed hospice reinstated Residents Ativan. Review of the fall investigation dated 12/24/25 at 7:41 P.M. for Resident #33 revealed she was found with her legs on the fall mat and upper body was on the bed. Resident #33 sustained skin tears to her left hand, left shin, and left index finger. The facility failed to list an immediate intervention. The follow up intervention was listed as padding was applied to the left side of the bed. Review of the fall investigation summary dated 10/11/25 revealed Resident #33 was found on the floor. She sustained a Page 1 of 6 365470 365470 12/31/2025 Ohio Living Llanfair 1701 Llanfair Avenue Cincinnati, OH 45224

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few skin tear to her left leg. No immediate intervention was listed. The follow up intervention was listed as the hospice nurse came in and assessed Resident #33 post fall. Interview with the Director of Nursing (DON) on 12/30/25 at 2:22 P.M. revealed if a resident has a fall the staff are to notify the nurse. The nurse will evaluate the resident and determine the next step. The nurse will notify the family and physician of the fall. The DON confirmed the nurse is expected to determine the immediate intervention and document the immediate intervention in the medical chart. The DON confirmed the facility failed to identify and document an immediate intervention for Resident #33's falls on 10/11/25, 12/14/25 and 12/24/25. 2. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: fracture of unspecified part of neck of right femur, unspecified atrial fibrillation, and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup or cleanup assistance for eating, supervision or touching assistance for oral hygiene, substantial/maximal assistance for toileting, partial/moderate assistance for showering/bathing, partial/moderate assistance for dressing, and partial/moderate assistance for personal hygiene. Resident is frequently incontinent of bowel and bladder. Review of Resident #5's fall risk assessment dated on 10/20/25 at 5:47 P.M. revealed Resident #5 to be a high fall risk. Review of the fall investigation for Resident #5 revealed on 12/22/25 at 8:57 P.M. revealed Resident #5 stood up in the shower and slid down the wall and was found sitting on her buttocks while Certified Nurse Assistant (CNA) #194 stepped out of the bathroom. Review of CNA #194 witness statement revealed CNA #194 stepped out of the bathroom when Resident #5 fell in the shower. Review of Licensed Practical Nurse (LPN) #172 revealed CNA #194 was standing outside the bathroom with the door cracked open when Resident #5 fell. Review of the Witness statement from CNA #194 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell. Review of the witness statement from LPN #172 revealed CNA #194 stepped out of the bathroom when Resident #5 was in the shower and fell. Interview on 12/30/25 at 2:03 P.M. with DON confirmed CNA #194 should never have left Resident #5 alone in the bathroom. Interview on 12/30/25 at 3:19 P.M. with CNA #194 confirmed they stepped out of the bathroom and had a hand on the bathroom door when Resident #5 fell in the shower. CNA #194 also stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed. Interview on 12/30/25 at 4:47 P.M. with LPN #172 confirmed CNA #194 stepped out of the bathroom and 365470 Page 2 of 6 365470 12/31/2025 Ohio Living Llanfair 1701 Llanfair Avenue Cincinnati, OH 45224

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a hand on the bathroom doorknob when Resident #5 fell in the shower. LPN #172 stated they were educated not to leave the resident alone in the shower, to always keep an eye on the resident, and if the resident is verbally abusive to get the resident out of the shower and backed in bed. Review of the education form for CNA #194 dated on 12/23/25 revealed CNA #194 stepped away from a resident while the resident was in the shower. The education form states all staff must stay within reach of residents while they are in the shower. Review of the facility policy titled, Fall Prevention and Management dated on 04/01/2003 and revised on 01/28/23 revealed at a time of a fall is the loss of an upright position that results in landing on the floor. 365470 Page 3 of 6 365470 12/31/2025 Ohio Living Llanfair 1701 Llanfair Avenue Cincinnati, OH 45224

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy revealed the facility failed to ensure medications are properly stored. This had the potential to affect one resident (#5) out of nine residents observed for medication storage. The facility also failed to ensure medications are labeled properly and not expired. This affected one (#3) of nine residents reviewed for medication labeling with the potential to affect all residents. The facility census was 33.1. Observation on [DATE] revealed Resident #5 was lying in bed asleep with her morning medications in a cup on the bedside table. Interview on [DATE] at 10:20 A.M with Licensed Practical Nursing (LPN) #8 confirmed medications were left on the bedside table. Review of Resident #5's Medication Administration Record (MAR) revealed in the medications in the cup there was Citalopram 20 milligrams (mg), cranberry tablet 450 mg, Eliquis 5 mg, famotidine 20 mg, Lisinopril 40 mg, Methenamine 1 gram, Senna-s 8.6 -50 mg, and acetaminophen 325 mg. 2. Observation on [DATE] at 4:37 P.M. of Rehab Medication Storage room with the Director of Nursing (DON) revealed an open tuberculin vial with no open date. Interview on [DATE] at 4:38 PM with the DON confirmed the open tuberculin vial did not have an open date and was supposed to. 3. Observation on [DATE] at 4:40 PM of the Rehab Medication Cart #2 revealed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Interview on [DATE] at 4:41 P.M. with Licensed Practical Nurse (LPN) #8 confirmed Resident #3 had Humalog U-100 insulin (insulin Lispro) solution with an open date for [DATE]. Record Review for Resident #3 Medication Administration Record (MAR) revealed Resident #3 had an order, Humalog U-100 insulin (insulin Lispro) solution 100 units, dated for [DATE] - [DATE] and the same order dated [DATE] - [DATE]. The MAR also revealed the last date the Humalog U-100 insulin (insulin Lispro) solution 100 units was administered on [DATE]. Review of the facility policy titled, Medication Storage dated on [DATE] revealed all prescription medications shall be kept in locked storage areas and separate from materials that may contaminate the medicines and drugs. Review of the facility policy titled, Medication Administration dated on 01/2025 revealed Multi dose vials: Must have an open date for 28 days or per manufacturer's guidelines. The policy also stated the resident is always observed after administration to ensure that the dose was completely ingested. 365470 Page 4 of 6 365470 12/31/2025 Ohio Living Llanfair 1701 Llanfair Avenue Cincinnati, OH 45224

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility policy review, the facility failed to provide a clean and sanitary kitchen in the main kitchen, failed to ensure the dishwasher properly sanitized the dishes on the Memory Care Unit, and failed to ensure the dietary staff utilize the use of hair nets. This had the potential to affect all residents who receive food from the kitchen. The facility identified all 33 residents receive food from the kitchen. The facility census was 33.1. Observation on 12/29/25 at 9:35 A.M. of Certified Nurse Assistant (CNA #178) revealed CNA #178 was hand washing the dishes in the Memory Care Unit kitchen with a regular household dish liquid and placed the dishes in the dishwasher. CNA #178 was not wearing a hair net. Continued observation of CNA #178 utilizes the dishwasher revealed neither the rinse or wash reached above 130 Fahrenheit (F) and the dishwasher was flashing add sanitizer.Interview on 12/29/25 at 9:35 A.M. with CNA #178 verified she was hand washing dishes in household detergent without a hair net. CNA #178 confirmed she does not utilize sanitizer in the sink because she utilizes the dishwasher. CNA #178 read the front of the dishwasher that confirmed the wash cycle should reach 160 degrees F and the rinse cycle should reach 180 degrees F if sanitizer is not used in the dishwasher. CNA #178 confirmed the dishwasher stated the temperature should reach 130 degrees F if sanitizer is being used. CNA #178 confirmed she ran the dishwasher a total of three times and each time the dishwasher continuously flashed add sanitizer. CNA #178 confirmed the dishwasher did not reach higher than 130 degrees F. CNA #178 confirmed the facility failed to maintain a dishwasher temperature log for the memory care unit. Interview on 12/29/25 at 11:22 A.M. with Dietary Manager (DM) #401 confirmed the dishwasher in the Memory Care Unit was flashing add sanitizer. DM #401 confirmed the facility failed to maintain a temperature log for the Memory Care Unit dishwasher. Review of the dishwasher temperature logs revealed the Memory Care kitchen did not have a dishwasher temperature log to review. 2. Observation on 12/30/25 at 11:45 A.M. with Registered Dietician (RD) #400 revealed the ceiling vents above the milk freezer near the food preparation table had dirt, and fuzzy debris hanging from it.Interview on 12/30/25 at 11:45 A.M. with RD #400 confirmed the kitchen vent had dirt, and fuzzy debris hanging from it. RD #400 confirmed the vent over milk freezer and food preparation area had dirt, fuzzy debris hanging from it.Review of the facility policy titled, Cleaning Dishes/Dish Machine, dated 2023, confirmed all flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning. Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. Confirm that soap and rinse dispensers are filled and have enough clearing products for the shift. Further review of the policy revealed the staff should check the dish machine gauges throughout the cycle to ensure proper temperatures for sanitation. Review of the facility policy titled, Employee Hygiene for Food Safety, dated 2023 confirmed the facility staff will wear hair restraints (hairnet or hat) to prevent hair from contacting exposed food. Review of the undated facility policy titled, General Sanitation of Kitchen, confirmed the cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Employees will be trained in how to perform cleaning tasks. 365470 Page 5 of 6 365470 12/31/2025 Ohio Living Llanfair 1701 Llanfair Avenue Cincinnati, OH 45224

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to maintain record of pneumococcal vaccine administration and failed to offer pneumococcal vaccines to residents. This impacted two residents (#18 and #33) of five residents reviewed for pneumococcal vaccine administration. The facility census was 33. 1. Record review for Resident #18 revealed resident was admitted on [DATE] with diagnoses including need for assistance with personal care; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; other asthma; and respiratory disorders in diseases classified elsewhere. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Resident #18 had no behaviors, required setup assistance for eating and oral hygiene, substantial assistance for toileting, bathing, and upper and lower body dressing, and supervision assistance for personal hygiene, and resident refused mobility assessment.Further record review for Resident #18 revealed no documentation indicating the resident and/or resident's representative were offered a pneumococcal vaccine since admission. Record review also revealed no documentation of pneumococcal vaccine administration prior to admission.Interview on 12/31/2025 at 8:01 A.M. with Director of Nursing (DON) revealed the resident and/or resident's representative declined a pneumococcal vaccine in 2023. The DON further reported that a pneumococcal vaccine had not been offered to the resident and/or the resident's representative since declination in 2023.2. Record review for Resident #33 revealed resident was admitted on [DATE] with diagnoses that included repeat falls; psychotic disorder with delusions due to known physiological condition; transient cerebral ischemic attack, unspecified (history of); other asthma; muscle weakness (generalized); depression, unspecified; anxiety disorder, unspecified; delusional disorders; and respiratory disorders in diseases classified elsewhere. Review of the MDS dated [DATE] revealed Resident #33 was moderately cognitively impaired, and the MDS dated [DATE] revealed the resident rejected care four to six days a week. In addition, MDS dated [DATE] revealed Resident #33 required setup assistance for eating and oral hygiene, substantial assistance with upper body dressing and personal hygiene, was dependent for toileting, bathing, lower body dressing, sit to lying, lying to sitting, sit to stand, and transfers.Further record review for Resident #33 revealed resident received pneumococcal vaccine (PCV - 13) on 05/20/2015. Documentation review revealed no additional pneumococcal vaccines were offered to the resident and/or the resident's representative since admission.Interview on 12/31/2025 at 8:01 A.M. with DON revealed that the resident and/or resident's representative was not offered a pneumococcal vaccine since admission.Review of a document titled Influenza and Pneumococcal Vaccines with a revised date of 10/05/2025 revealed that Each resident is offered .pneumococcal immunization at least once, unless immunization is medically contraindicated, or the resident has already been immunized with pneumococcal vaccine within the past five years. Residents Affected - Few 365470 Page 6 of 6