Health inspection·February 8, 2024

F 0584 facility were cold. Level of Harm - Minimal harm or potential for actual harm Interview on 02/07/24 at 9:50 A.M. with RN #45 revealed the facility did not have any hot water to wash his hands. Residents Affected - Some Interview on 02/07/24 at 9:52 A.M. with Resident #23 revealed he took a shower Sunday and the shower water fluctuated between being hot and being cold. Interview on 02/07/24 at 9:56 A.M. with Resident #47 revealed the water temperature in the facility fluctuated between being hot and being cold. Observation of water temperatures on the 400 unit with Maintenance Director #72 on 02/07/24 at 10:51 A.M. revealed the following: • Resident #05's room water temperature was 55 degrees Fahrenheit with no water pressure. • Resident #07's room water temperature was 69 degrees Fahrenheit with no water pressure. • Residents #33 and #34's room water temperature was 69 degrees Fahrenheit. • The secured unit shower room was 74 degrees Fahrenheit and immediately went to 65 degrees Fahrenheit, and the middle shower room did not have running water in the sink or shower. Observation of water temperatures on the 200 unit with Maintenance Director #72 on 02/07/24 at 11:00 A.M. revealed the following: • Residents #11 and #47's room water temperature was 81 degrees Fahrenheit. • The 200-unit front center shower room was 79 degrees Fahrenheit. Interview with Maintenance Director #72 on 02/07/24 at 10:51 A.M. verified the aforementioned Residents room water temperatures and the middle shower room did not have running water in the sink or shower. Telephone interview with Plumbing Contractor #800 on 02/07/24 at 11:43 A.M. revealed the plumbing contractor was notified that one of the facility's two boilers had malfunctioned on 01/28/24. Plumbing Contractor #800 stated the company came to the facility on [DATE] to look at the boiler and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 2 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 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 - Some provided an estimate to the facility on [DATE] for a new boiler. Plumbing Contractor #800 confirmed the facility sent the contractor a check for the new boiler of 02/05/24 and it was ordered and was expected to arrive at the end of the week. Telephone interview with Admissions Director #63 on 02/07/24 at 12:48 P.M. revealed she took the temperatures on 01/29/24 but she only took temperatures of the front center shower room and the 200 hallway because the boiler was not working for other areas of the facility and the water temperatures were cold. Admissions Director #63 stated that she was made aware that the boiler was not working on 01/28/24. Admissions Director #63 reported residents that resided in the impacted rooms were taking showers in the front shower rooms and staff were going into empty rooms and getting basins of hot water. Interview on 02/07/24 at 1:59 P.M. with State Tested Nurse Aide (STNA) #05 revealed all the water was cold in the facility. Interview with the Administrator on 02/08/24 at 3:50 P.M. revealed all residents on the side where the boiler was not functioning received showers on the unit where the functioning boiler was located, and no showers were impacted by the boiler being out. The Administrator reported one of the facility's two boilers that provided hot water went out on 01/28/24. The Administrator reported the facility had to get different quotes before a replacement boiler could be ordered and installed. The Administrator reported the facility sent a check to the contractor on 02/05/24 for the new boiler; however, did not have a time frame of when the new boiler would be installed. Review of email correspondence from the Administrator dated 02/07/24 at 4:39 P.M. revealed 23 Residents (#01, #03, #05, #07, #10, #12 #14, #16, #19, #24, #27, #29, #32, #33, #34, #37, #38, #39, #40, #44, #45, #46 and #52) were in rooms affected by the boiler not functioning. Review of the facility's plumbing proposal dated 01/29/24 revealed the total price for the boiler replacement was $19,620 dollars. The proposal was accepted on 02/05/24 by the Administrator. Review of the facility's check to the plumbing contractor dated 02/05/24 revealed the facility paid the plumbing contractor $19,620 dollars. Review of the facility's safety of water temperatures policy dated December 2009 revealed water heaters that service resident rooms, bathrooms, common areas and shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation. Review of the facility policy titled Quality of Life - Homelike Environment revealed residents are provided a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Complaint Number OH00150761. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 3 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review and staff interviews, the facility failed to ensure the dishwasher temperature and water temperatures in the kitchen were maintained in manner to promote kitchen sanitation. This affected 54 of the 54 residents who the facility identified as receiving food from the kitchen. The facility census was 54. Findings include: Observation of Maintenance Director #72 taking water temperatures in the facility on 02/07/24 at 10:51 A.M. revealed the handwashing sink in the kitchen was 72 degrees Fahrenheit, the dishwasher registered 71 degrees Fahrenheit for the wash and rinse, and the three-compartment sink was 87 degrees Fahrenheit. Dietary Aide #13 was actively washing pans in the three-compartment sink. Interview with Maintenance Director #72 on 02/07/24 at 10:51 A.M. verified the handwashing sink in the kitchen was 72 degrees Fahrenheit, the dishwasher registered 71 degrees Fahrenheit for the wash and rinse, and the three-compartment sink was 87 degrees Fahrenheit. Maintenance Director #72 also verified Dietary Aide #13 was actively washing pans in the three-compartment sink. Maintenance Director ##72 reported the dishwasher was a low temperature /chemical dishwasher and the temperatures should be at minimum 120 degrees Fahrenheit for wash and 150 degrees Fahrenheit for the wash cycle. Observation of the facility's kitchen on 02/07/24 at 2:00 P.M. revealed Dietary Aide #13 was running lunch dishes through the dishwasher. The dishwasher wash and rinse registered 70 degrees Fahrenheit. The chemical was approximately 150 parts per million (ppm). Interview on 02/07/24 at 2:00 P.M. with Dietary Aide #13 verified she was running lunch dishes in the dishwasher and the dishwasher wash and rinse were 70 degrees Fahrenheit. Interview on 02/07/24 at 2:00 P.M. with Dietary Manager #16 verified Dietary Aide #13 was running lunch dishes in the dishwasher and the dishwasher wash and rinse were 70 degrees Fahrenheit and the chemical was approximately 150 parts per million. Review of the dishwasher temperature log dated 02/07/24 revealed the breakfast dishwasher wash and rinse temperature were 85 degrees Fahrenheit and the lunch dishwasher wash and rinse temperature were 85 degrees Fahrenheit. Review of the sanitation policy dated October 2009 revealed the dishwasher temperature for a low temperature dishwasher should be 120 degrees Fahrenheit for the wash and a final rinse with 50 parts per million hypochlorite for at least ten seconds. This deficiency represents non-compliance investigated under Complaint Number OH00150761. This deficiency is an example of continued non-compliance from the survey dated 01/04/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 4 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and review of facility policy, the facility failed to maintain essential equipment to provide hot water to the residents. This directly affected 23 (#01, #03, #05, #07, #10, #12 #14, #16, #19, #24, #27, #29, #32, #33, #34, #34, #34, #37, #38, #39, #40, #44, #46 and #52) of the 54 residents reviewed for safe and comfortable hot water temperatures. This also had the potential to affect all 54 residents who resided in the facility. Residents Affected - Some Findings include: Interview on 02/07/24 at 9:35 A.M. with Housekeeper #42 revealed the water was cold in the facility. Interview on 02/07/24 at 9:37 A.M. with Registered Nurse (RN) #66 revealed the center unit was the only unit with hot water in the facility. RN #66 stated all other units did not have hot water. Interview with Resident #07 on 02/07/24 at 9:39 A.M. revealed the water at the facility was cold and she wanted a warm shower. Interview on 02/07/24 at 9:46 A.M. with Resident #05 revealed the water in the facility was cold when she took a shower. Interview on 02/07/24 at 9:50 A.M. with RN #45 revealed the facility did not have any hot water. Interview on 02/07/24 at 9:52 A.M. with Resident #23 revealed he took a shower Sunday and the shower water fluctuated between being hot and being cold. Interview on 02/07/24 at 9:56 A.M. with Resident #47 revealed the water temperature in the facility fluctuated between being hot and being cold. An interview with the Administrator on 02/07/24 at 10:13 A.M. revealed one of the facility's two boilers went out on 01/28/24 but staff were taking residents to the front center shower room because the water temperature was in range in that shower room. Observation of water temperatures on the 400 unit with Maintenance Director #72 on 02/07/24 at 10:51 A.M. revealed the following: • Resident #05's room water temperature was 55 degrees Fahrenheit with no water pressure. • Resident #07's room water temperature was 69 degrees Fahrenheit with no water pressure. • Residents #43 and #15's room water temperature was 89 degrees Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 5 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 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 • Level of Harm - Minimal harm or potential for actual harm Resident #26's room water temperature was 64 degrees Fahrenheit. • Residents Affected - Some Residents #33 and #34's room water temperature was 69 degrees Fahrenheit. • The secured unit shower room was 74 degrees Fahrenheit and immediately went to 65 degrees Fahrenheit, and the middle shower room did not have running water in the sink or shower. Observation of water temperatures on the 200 unit with Maintenance Director #72 on 02/07/24 at 11:00 A.M. revealed the following: • Residents #11 and #47's room water temperature was 81 degrees Fahrenheit. • Resident #41's room water temperature was 103 degrees Fahrenheit. • The 200-unit front center shower room was 79 degrees Fahrenheit. Observation of water temperatures on the 300 unit with Maintenance Director #72 on 02/07/24 at 11:05 A.M. revealed the following: • Resident #08 and room water temperature was 70 degrees Fahrenheit. • Resident #48's room water temperature was 70 degrees Fahrenheit. Observation of water temperatures in the kitchen with Maintenance Director #72 on 02/07/24 at 11:10 A.M. revealed the handwashing sink in the kitchen was 72 degrees Fahrenheit, the dishwasher was at 71 degrees Fahrenheit for the wash and the rinse cycles, and the three-compartment sink water was 87 degrees Fahrenheit. Telephone interview with Plumbing Contractor #800 on 02/07/24 at 11:43 A.M. revealed the plumbing contractor was notified that one of the facility's two boilers had malfunctioned on 01/28/24. Plumbing Contractor #800 stated the company came to the facility on [DATE] to look at the boiler and provided an estimate to the facility on [DATE] for a new boiler. Plumbing Contractor #800 confirmed the facility sent the contractor a check for the new boiler of 02/05/24 and it was ordered and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 6 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 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 expected to arrive at the end of the week. Level of Harm - Minimal harm or potential for actual harm Telephone interview with Admissions Director #63 on 02/07/24 at 12:48 P.M. revealed she took the water temperatures on 01/29/24 but she only took water temperatures of the front center shower room and the 200 hallway because the boiler was not working for other areas of the facility and the water temperatures were cold. Admissions Director #63 stated that she was made aware that the boiler was not working on 01/28/24. Admissions Director #63 reported residents that resided in the impacted rooms were taking showers in the front shower rooms and staff were going into empty rooms and getting basins of hot water. Residents Affected - Some Interview on 02/07/24 at 1:59 P.M. with State Tested Nurse Aide (STNA) #05 revealed all the water was cold in the facility. Review of email correspondence from the Administrator dated 02/07/24 at 4:39 P.M. revealed 23 Residents (#01, #03, #05, #07, #10, #12 #14, #16, #19, #24, #27, #29, #32, #33, #34, #37, #38, #39, #40, #44, #45, #46 and #52) were in rooms that did not have hot water due to the malfunctioning boiler. Interview with outside Heating Ventilation Air Conditioning (HVAC) contractor Staff #801, #802 and #803 on 02/08/24 at 10:00 A.M. revealed they were not contracted to do the facility's routine maintenance on the boiler system; however, they were trying to get the facility to contract with them to do the routine HVAC maintenance. Outside contractor Staff #801, #802 and #803 indicated the facility's boiler system should have routine maintenance scheduled yearly as part a preventative maintenance plan. Outside contractor Staff #801, #802 and #803 indicated they were contracted to install a new boiler system to regain hot water on the side of the building that was not getting hot water. Interview with the Administrator on 02/08/24 at 3:50 P.M. revealed the facility had to get different quotes before a replacement boiler could be ordered and installed. The Administrator reported the facility sent a check to the contractor on 02/05/24 for the new boiler; however, did not have a time frame of when the new boiler would be installed. The Administrator verified the facility had no documented evidence of any routine or preventative maintenance on the boiler system. Review of routine maintenance on the facility's boiler from 02/07/23 to 02/08/24 revealed no documented evidence the facility's boiler system had any routine maintenance on the boiler system or when the last routine maintenance was performed. Review of the water temperature logs from 01/29/24 through 02/08/24 revealed the boiler was down for 400 unit and part of the 100 unit and not water temperatures were tested. Review of the State of Ohio Department of Commerce inspection report dated 01/11/24 revealed the flow sensing device was leaking and must be replaced with an approved type and size by a qualified repair concern. Review of the plumbing contractor finished work order dated 01/17/24 revealed the flow switch was replaced and hot water was running to the dishwasher and sink at 120 degrees Fahrenheit. Review of the plumbing contractor work invoice dated 01/25/24 revealed the contractor went to the kitchen to check the hot water. The sink had hot water and it was 120 degrees Fahrenheit. The boiler was working properly at that time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 7 of 8 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 365476 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Astoria Place of Silverton 6922 Ohio Avenue Cincinnati, OH 45236 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 Level of Harm - Minimal harm or potential for actual harm Review of the facility's plumbing proposal dated 01/29/24 revealed the total price for the boiler replacement was $19,620.00 dollars. The proposal was accepted on 02/05/24 by the Administrator. Review of the facility's check to the plumbing contractor dated 02/05/24 revealed the facility paid the plumbing contractor $19,620.00 dollars for the new boiler. Residents Affected - Some Review of the facility's safety of water temperatures policy dated December 2009 revealed water heaters that service resident rooms, bathrooms, common areas and shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation. This deficiency represents non-compliance investigated under Complaint Number OH00150761. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365476 If continuation sheet Page 8 of 8