Health inspection·April 14, 2022

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, staff interview, and policy review, the facility failed to properly prepare medications for administration. This had the potential to affect three Residents (#15, #23, and #59) out of 25 residents who reside on the Oak and Pine unit. The facility census was 87. Findings include: Observation on 04/12/22 at 2:59 P.M. of the medication cart on the Oak and Pine unit revealed there were three cups of pre-poured medications prepared for three Residents (#15, #23, and #59) in the top drawer of the cart. Interview with Licensed Practical Nurse (LPN) #80 during the observation on 04/12/22 at 2:59 P.M. revealed the medications pre-poured for Resident #15 included two glyburide five milligrams (mg) pills, the medication pre-poured for Resident #23 included percocet (controlled opoid) 7.5/325 mg, and the medications pre-poured for Resident #59 were robaxin 500 mg and percocet 7.5/325 mg. Interview on 04/12/22 at 3:05 P.M. with the Manager of Clinical Services #87 verified the medications were prepared improperly for Resident #15, #23, and #59, when the medications were pre-poured into a cup and set in the top drawer of the medication cart. Review of the General Guidelines for Medication Administration Policy, dated 06/21/17, revealed only one resident's medication at a time should be prepared and taken into the resident's room. Pre-pouring medications is not an acceptable or safe practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365480 If continuation sheet Page 2 of 4 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 365480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Salem Woods 6164 Salem Road Cincinnati, OH 45230 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 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, review of medication insert, and policy review, the facility failed to ensure medications were dated after opening and were not expired. This had the potential to affect all 87 residents residing in the facility. The facility census was 87. Findings include: 1. Observation on [DATE] at 1:42 P.M. of the medication storage room revealed two 16-ounce bottles of liquid Docusate Sodium Stool Softener with an expiration date of 09/2020. Interview on [DATE] at 1:43 P.M. with Licensed Practical Nurse #36 confirmed the expiration date on the two Docusate Sodium Stool Softener bottles. 2. Observation on [DATE] at 2:00 P.M. of the refrigerator on the 300 Hall revealed a vial of Aplisol (Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution]), used for diagnosing tuberculosis, was opened but was not dated. Interview on [DATE] at 2:01 P.M. with Registered Nurse #89 confirmed the tuberculin solution was opened with no date marked to indicate when the solution had been opened. Review of the packaging insert for the tuberculin solution, revised 03/2016, revealed vials in use for more than 30 days should be discarded. Review of the facility policy titled Medication Storage, dated [DATE], revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365480 If continuation sheet Page 3 of 4 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 365480 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Salem Woods 6164 Salem Road Cincinnati, OH 45230 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of facility recipes, and policy review, the facility failed to properly prepare pureed food. This had the potential to affect all eight facility identified residents (#9, #10, #17, #29, #40, #47, #49, and #56) in the facility who receive a pureed diet. The facility census was 87. Residents Affected - Some Findings include: Observation on 04/12/22 at 9:23 A.M. revealed [NAME] #21 prepared pureed ham for the lunch meal. [NAME] #21 stated there was one pureed diet, which was liquified, and the remainder of the pureed diets were standard puree. [NAME] #21 placed ham into the food processor, turned the food processor on, and then added water to the food processor. [NAME] #21 continued to add water to the food processor until the ham was a watery consistency. [NAME] #21 then scooped a portion of the liquified ham mixture into an insulated bowl and informed the surveyor the contents in the bowl were for the liquified pureed diet. [NAME] #21 then added thickening powder to the ham mixture to create an appropriate pureed-textured ham for the remainder of the pureed diets. Continued observation on 04/12/22 at approximately 9:30 A.M. revealed [NAME] #21 placed green beans into the food processor to begin preparing the pureed green beans. [NAME] #21 turned on the food processor and began adding water as well as a small amount of thickener to the green beans until the appropriate consistency was achieved. Interview on 04/12/22 at approximately 9:35 A.M. with [NAME] #21, verified he prepared the pureed liquified diet by adding enough water to the ham to make all of the ham liquified and utilized thickener to thicken the mixture back to a pureed form, unnecessarily adding more liquid to all of the pureed ham. [NAME] #21 stated he has always done it that way. Interview on 04/13/22 at approximately 12:15 P.M. with Registered Dietitian (RD) #88, verified water should not be used to aid in the process of making pureed foods. Interview on 04/13/22 at 12:42 P.M. with Dietary Supervisor #65, verified [NAME] #21 used water when making the pureed ham and pureed green beans on 04/12/22. Review of the Recipe Summary Card titled Pureed Meats (Protein) revealed food should be pureed until meats with a little stock/cooking liquid reach a smooth consistency. If needed, add additional stock or liquid to reach a smooth consistency and add thickener to achieve a mashed potato consistency. Review of the Recipe Summary Card titled Pureed Vegetables revealed food should be pureed until vegetables reach a smooth consistency. If needed, stock or liquid can be added to reach a smooth consistency and add thickener to achieve mashed potato consistency. Review of the facility policy titled Procedure for Thinned-Puree, undated, revealed pureed food was to be prepared according to the recipe and, prior to adding the thickening agent, remove one portion of the food needed to be thinned. The cook should then use broth, milk, juice, or half and half to thin the pureed item, adding one ounce of liquid at a time to achieve the desired consistency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365480 If continuation sheet Page 4 of 4