Inspection·November 2, 2023

F 0660 Level of Harm - Minimal harm or potential for actual harm medication cards, she must have also grabbed some of Resident #13's medications. LPN #20 was very apologetic for what happened and stated she possibly made the mistake due to Resident #10 and a family friend going back and forth about Resident #10 needing his medications. Resident #10 was on the phone with the pharmacy to pick up his medications. LPN #20 stated it was decided Resident #10 should just take his medications with him just in case he needed them. Residents Affected - Few Review of a facility investigation document titled Medication Administration Error dated 10/06/23, revealed the facility learned of a medication error incident which occurred on 09/22/23 and it was not reported to the facility until 10/04/23. The facility indicated LPN #20 discharged Resident #10 from the facility to home and gave him medications belonging to Resident #13. Resident #10 proceeded to take the wrong medications for several days before the error was identified by his daughter. Resident #10's daughter notified the Ombudsman, who then notified the facility on 10/04/23. The Ombudsman had pictures of the medications that were sent home with Resident #10 which showed the medications were ordered for Resident #13. LPN #20 confirmed she accidentally gave the additional medications to Resident #10 when he was discharged . LPN #20 noted it was a mistake and she had already provided a statement to the facility. An interview with the Administrator and the DON on 10/26/23 at 3:30 P.M. revealed they were informed by the Ombudsman on 10/04/23 about LPN #20 sending the wrong medications home with Resident #10 and the facility immediately started an investigation. DON indicated Resident #10 was sent home with Potassium Chloride (potassium supplement) 20 milliequivalents (meqs) daily, Atorvastatin (cholesterol) 10 milligrams (mgs) daily, Levetiracetam (anti-seizure) 500 mgs twice daily, and Gabapentin 200 mgs (neuropathy) daily on 09/22/23 as the resident was discharged . The Administrator and DON stated that they tried to reach out to Resident #10 but there was no answer. An interview with Resident #10's daughter on 11/01/23 at 1:20 P.M., revealed Resident #10 stated he was not feeling good when the daughter went to his house, she reviewed the medications give the resident upon discharge, and noticed some of the medications belonged to another resident at the facility. Resident #10's daughter attempted to get the resident to go to the hospital; however, the resident said he was feeling better because he had stopped taking the medications two days prior. An attempted telephone interview with LPN #20 on 11/01/23 at approximately 2:30 P.M. and no contact was made. A telephone interview with Resident #10 on 11/01/23 at 4:15 P.M., indicated he believed he was ordered new medications and he thought that Resident #13's name on the medication cards was the name of the doctor since they were all the same, so he took the medications according to the directions. Resident #10 stated the medications made him feel bad, so he called his physician who informed the resident to stop the medications until he was seen in the office for his appointment on 09/29/23. Resident #10 stated he stopped taking the medication on Wednesday 09/27/23. Interview with the DON and the Administrator on 11/01/23 at 5:15 P.M., verified there was no documented evidence of an order and/or communication for any home health care services being set up prior to Resident #10's discharge on [DATE]. A telephone interview with Transition of Care Assistant (TCA) #30 on 11/02/23 at 9:27 A.M., revealed she works at Resident #10's primary care physician's office and when she talked to Resident #10, she believed the facility did not do a very good discharge because Resident #10 was supposed to receive home health care services, but nobody ever came or called the resident to start any services. TCA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 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 365551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clovernook Health Care and Rehabilitation Center 7025 Clovernook Avenue Cincinnati, OH 45231 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 0660 #30 stated that she arranged for home health care services for Resident #10 after he called the office. Level of Harm - Minimal harm or potential for actual harm A telephone interview with Executive Director (ED) #21 at Spirit Homecare and Hospice on 11/02/23 at 3:45 P.M. revealed his office received a facsimile (fax) on 09/27/23 (after hours) from the facility and the coversheet indicated Resident #10 was discharged on 09/23/23 and now wanted home health services. ED #21 noted the documents showed they were printed on 09/27/23 at 7:00 P.M. and home care services were ordered by the facility's Medical Director (MD) #35. ED #21 noted the Case Manager / Registered Nurse (RN) called Resident #10 on 09/28/23 and again on 09/29/23 and left messages about the start of his home care services. ED #21 noted the Case Manager /RN called the resident on 09/30/23 and the resident requested for the home care services to start on 10/03/23. On 10/03/23 when the Case Manager / RN arrived at Resident #10's house, the resident refused the home health care services and stated he was active with another home care agency. Residents Affected - Few Review of the 06/01/08 facility policy titled Admission, Transfer, and Discharge Register revealed the register should have the resident's name, admission date, medical record number, age and sex, room number, attending physician, from where the resident was admitted , the date for transfer/discharge, reason for transfer/discharge, place where resident is transferring/discharging to, and length of stay. This deficiency represents non-compliance investigated under Complaint Number OH00147118. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 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 365551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clovernook Health Care and Rehabilitation Center 7025 Clovernook Avenue Cincinnati, OH 45231 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a discharge summary of recapitulation of resident's stay. This affected one (#10) out of three residents reviewed for discharge rights. The facility census was 108. Findings include: Review of the closed medical record for Resident #10 revealed the resident was admitted on [DATE] and discharged home on [DATE]. Diagnoses included osteoarthritis, diabetes mellitus, left knee replacement, intracerebral hemorrhage, and morbid obesity. Review of the five-day Minimum Data Set (MDS) assessment 3.0 dated 09/21/23 for Resident #10, revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs). Review of the care plan dated 09/15/23 for Resident #10, revealed the resident was admitted in the facility for short term rehabilitation (rehab) and would have a safe discharge to the community after completing rehab with skilled nursing care and therapy. Review of the medical record for Resident #10 with the Administrator and Director of Nursing (DON) revealed there was no documented evidence of a discharge recapitulation or summary completed for Resident #10 when the resident was discharged on 09/22/23. An interview with the Administrator and the DON on 11/01/23 at 5:15 P.M., verified there was no documented evidence of a discharge recapitulation summary completed for Resident #10. This deficiency represents non-compliance investigated under Complaint Number OH00147118. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 4 of 4