Inspection·January 5, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to promptly notify the resident representative when residents tested positive for COVID-19 and/or were exposed to COVID-19 and were placed under isolation precautions. This affected two (Residents #38 and #105) of three residents reviewed for notification of change. The census was 104. Findings include: 1. Review of Resident #38's medical record revealed Resident #38 was admitted to the facility on [DATE]. Resident #38's diagnoses included but were not limited to hemiplegia and hemiparesis, hydrocephalus, epilepsy, cognitive communication deficit, dysphagia, dementia, major depressive disorder, and adjustment disorder with anxiety. Review of Resident #38's Minimum Data Set (MDS) assessment, dated 11/27/23, revealed Resident #38 had mild cognitive impairment. Review of Resident #38's medical profile revealed Resident #38's wife was deemed guardian of person. Review of Resident #38's medical record revealed no evidence Resident #38's wife was notified when Resident #38 was placed under isolation precautions on 12/01/23 due to having been exposed to COVID-19 by his roommate (Resident #105). 2. Review of Resident #105's medical record revealed Resident #105 was admitted to the facility on [DATE]. Resident #105's diagnoses included but were not limited to bipolar disorder, hemiplegia and hemiparesis, unspecified intellectual disabilities, epilepsy, mood disorder, major depressive disorder, psychosis, moyamoya disease, and unspecified convulsions. Review of Resident #105's MDS assessment, dated 11/29/23, revealed Resident #105 had significant cognitive impairment. Review of Resident #105's medical profile revealed Resident #105 had a resident representative. Review of Resident #105's progress notes revealed Resident #105 tested positive for COVID-19 on 12/01/23. Review of Resident #105's medical record revealed no evidence Resident #105's resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365551 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 01/05/2024 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)