Inspection·May 28, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few there was no swelling, redness, or injuries noted. The vital signs were as follows: blood pressure (BP) 114/61 millimeters of mercury (mm/Hg), pulse 88 beats per minute, respirations 17 breaths per minute, temperature 97.2 degrees Fahrenheit (F), pulse oximetry 96 percent (%) on two-liters per minute (LPM) of oxygen per nasal cannula (NC). NP #40 was in the facility and examined Resident #15 with new orders to obtain an Xray of the resident's right knee. The root cause analysis (RCA) of the incident revealed STNA #30 failed to follow the company policy when utilizing a Hoyer mechanical lift. Interventions included terminating STNA #30, and a therapy evaluation and treatment were ordered for Resident #15. The follow-up to the investigation revealed the resident did not fall but the resident's leg and side of abdomen was hanging out of bed and the resident was transferred back to the bed improperly. Review of STNA #70's statement revealed on 12/20/23 he received a shift report from the two-night shift aides. Resident #15 had his call light on, so STNA #70 went to answer it and Resident #15 indicated he needed to be cleaned up. STNA #70 started to change the resident when he was yelling and crying saying he fell last night and his knee hurt. STNA #70 went to get another STNA to assist him when Resident #15 was yelling and crying so he told the nurse. Review of Xray results dated 12/21/23 for Resident #15 revealed the resident had a complete oblique fracture involving the distal third of the right femur with anterior lateral displacement of the distal fracture. Review of a Social Services progress note dated 12/21/23 at 4:37 P.M. for Resident #15, revealed the resident's Xray results were received and they were communicated to MD #35 who ordered the resident to be sent to the hospital due to a fracture of his right femur. Resident #15 was alert and oriented at time of departure with EMS. Review of the hospital records dated 12/21/23 for Resident #15, revealed the resident presented to the emergency room (ER) with a fall at the nursing home two days ago and then diagnosed with a hip fracture. The resident reported he fell out of the bed and his right leg went underneath him and he was having right hip pain. The resident had continued to complain of pain since the fall and was found to have a right femoral fracture at the nursing home. Another Xray was completed which showed the resident had a comminuted distal right femoral fracture redemonstrated with mild displacement/rotation at the fracture site, with extensive surrounding soft tissue swelling. An Orthopedic surgeon was consulted and the resident required an open reduction internal fixation (ORIF) with intramedullary nailing (a surgical procedure to repair the fracture) surgical procedure. The notes indicated the resident went into respiratory failure post-surgery and was transferred to the intensive care unit (ICU) for continued treatment. Resident #15 was discharged back to the facility on [DATE]. Review of STNA #76's undated witness statement revealed he worked on 12/19/23 from 7:00 P.M. to 7:00 A.M. (night shift) and upon coming in to work, Resident #15 was screaming, crying, throwing things at employees, and wanted to go to bed. STNA #76 transferred the resident to bed. STNA #76 reported he worked again on 12/20/23 (7:00 P.M. to 7:00 A.M.) and was questioned if Resident #15 fell out of bed on 12/19/23. STNA #76 reported the resident did not fall but STNA #30 had indicated Resident #15 was slipping out of bed, when he and STNA #30 had pushed him back in the bed. Review of LPN #45's undated witness statement revealed she worked on 12/19/23 from 7:00 P.M. to 7:00 A.M. and when she arrived for her shift, Resident #15 was at the nurse's station trying to call his family; however, the number was no longer working and Resident #15 became very upset and started yelling, crying, screaming, and throwing things at the staff. LPN #45 tried to call the number again (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 2 of 6 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 05/28/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few and the number was no longer in service. Resident #15 started yelling at the staff again. Resident #15 eventually calmed down and was placed in bed by the STNAs. LPN #45 was doing her medication administration, when she observed Resident #15 wrapped in a top sheet with his left leg out of the bed with his bottom close to the edge of the bed. LPN #45 went and got former STNA #30, and they adjusted the resident back in the bed by the bottom pad. Resident #15 was yelling that he wanted to call his family. LPN #45 reminded Resident #15 that they tried two times already and the number did not work. Review of former STNA #30's verbal statement via telephone dated 12/21/23 and authored by the DON, revealed when former STNA #30 came on shift on 12/19/23 at 7:00 P.M., Resident #15 was yelling and throwing items at him and the staff because he wanted to go to the bed. Former STNA #30 reported he and LPN #45 transferred the resident into the Hoyer lift and while Resident #15 was up in the air, STNA #30 had to swing the resident around the Hoyer pole to position him in the bed. Resident #15 started screaming my legs. Former STNA #30 reported he proceeded to move the resident's legs around the Hoyer pole, and he did not notice anything different about Resident #15's right leg until he performed care for him. Former STNA #30 stated Resident #15 was unable to move his right leg like normal, and STNA #30 reported this to LPN #45. The DON noted she contacted LPN #45 and she indicated she did not assist former STNA #30 with the Hoyer transfer and nothing about Resident #15's leg was reported to her. The DON noted she contacted former STNA #30 again and he retracted his statement and admitted he transferred Resident #15 by a Hoyer lift by himself. Former STNA #30 stated Resident #15 did not fall and the only time Resident #15 made mention of his leg was when the resident was being moved around the Hoyer pole. Former STNA #30 reported LPN #45 came out of the resident's room and asked him for assistance. When former STNA #30 entered the room, Resident #15's left leg was off the bed and his abdomen was slightly hanging off. STNA #30 reported he repositioned Resident #15 with a draw sheet while LPN #45 guided the resident's left leg and stomach back in the bed. Former STNA #30 stated Resident #15's right foot was wrapped in his blanket and the resident was yelling about wanting to use the phone while they repositioned him. Former STNA #30 was suspended pending an investigation by the DON. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively impaired and was dependent on staff for activities of daily living (ADLSs). Interview with the Administrator and Director of Nursing (DON) on 05/08/24 at approximately 4:00 P.M., revealed Resident #15 had an Xray completed on 12/21/23 which showed a fractured right femur. The facility started an investigation and learned of a Hoyer incident involving former STNA #30 and Resident #15 on 12/19/23. The DON stated former STNA #30 was immediately suspended pending the outcome of the investigation and was eventually terminated on 12/22/23 for failing to follow policy when transferring residents via Hoyer lift. The DON stated former STNA #30 had originally lied during his first interview by saying LPN #45 assisted him with transferring Resident #15 to the bed; however, when the DON questioned LPN #45 about the incident, LPN #45 denied helping STNA #30 with the Hoyer transfer. The DON reported she reinterviewed former STNA #30, and he admitted to transferring Resident #15 to the bed by himself and when he was swinging the resident's body towards the bed, Resident #15's leg hit the Hoyer bar and that was when Resident #15 started saying his knee hurts. Former STNA #30 stated he reported the incident to LPN #45; however, LPN #45 stated the incident was never reported to her and therefore nothing was documented about the incident. A telephone interview with MD #35 on 05/13/24 at 12:30 P.M., revealed he was never informed of any fall or an incident involving Resident #15 on 12/19/23; however, NP #40 reported to him on 12/20/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 3 of 6 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 05/28/2024 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)

F 0689 Level of Harm - Actual harm Residents Affected - Few Resident #15 was complaining of left leg pain, and she ordered an x-ray. MD #35 stated Resident #15 was often non-compliant with his care and had behaviors. MD #35 stated he learned of the resident's femur fracture after the Xray was completed on 12/21/23. A telephone interview with NP #40 on 05/13/24 at 2:32 P.M., revealed she was in the facility on 12/20/23 and saw Resident #15 due to him complaining of pain. Resident #15 complained of pain in his knee and hip, and she ordered an Xray. NP #40 could not recall which leg the resident complained about since she did not have his chart accessible. NP #40 reported she was never informed of the resident falling or an incident involving a Hoyer lift transfer. NP #40 also reported that Resident #15 is frequently confused especially when he refuses his lactulose, and his ammonia levels rise. A telephone interview with former STNA #30 on 05/13/24 at 3:21 P.M., revealed when he went into work on 12/19/23 for the night shift (7:00 P.M. to 7:00 A.M.) he was assigned to care for Resident #15. The resident was in a wheelchair at the nurse's desk at the start of his shift yelling and saying he was going to throw himself on the floor. Former STNA #30 stated he used a Hoyer for bigger people without assistance and transferred Resident #15 to his bed. Former STNA #30 denied hitting Resident #15's leg, denied the resident falling and stated he did everything correctly and the resident was placed in the bed with no issues. Former STNA #30 stated approximately one and a half hours later, he noticed Resident #15 was on the floor on his bottom with his back against the bed. Former STNA #30 reported the fall to LPN #45. STNA #76 came in the resident's room to assist them putting Resident #15 back into the bed and he was told by LPN #45 not to say anything about Resident #15 falling from the bed. STNA #30 stated they picked up the resident's legs and pushed/pulled until they got him back into the bed. A telephone interview with LPN #45 on 05/14/24 at 7:55 A.M., revealed when she came on shift on 12/19/23 at 7:00 P.M., Resident #15 was yelling, screaming, and throwing things, but this was a normal behavior. LPN #45 stated she asked Resident #15 how she could help, and he wanted to call his family, so LPN #45 assisted Resident #15 with making the phone call, but the number was not in service any longer. LPN #45 stated after helping Resident #15, she left the area to start her medication administration while former STNA #30 assisted Resident #15 to the bed. LPN #45 stated she was passing medications and was never asked by former STNA #30 to assist with the transfer. LPN #45 stated she was not aware that two staff members were required for Hoyer transfers. LPN #45 reported that while she was doing her rounds, she noticed Resident #15 was halfway off his bed with his left leg hanging off the bed. She got former STNA #30 to assist her with getting Resident #15 back in the bed and they pushed/pulled the resident until they got him back and positioned correctly in the bed. LPN #45 stated Resident #15 did not fall, he was only leaning off the bed. LPN #45 denied telling former STNA #30 not to report any fall because Resident #15 did not fall on 12/19/23. LPN #45 stated she could not remember if Resident #15 had any complaints of pain during the shift. A telephone interview with STNA #76 on 05/14/24 at 11:40 A.M., revealed he did not assist in any transfers and was never asked to help get Resident #15 off the floor. Review of the personnel file for former STNA #30 revealed a hire date of 12/07/22 with an active STNA certification, no former disciplinary actions, no coachable moments, no prior resident complaints, and he was terminated by telephone on 12/22/23 for failing to follow the company policy when utilizing a Hoyer lift. Review of Hoyer Lift Manufacturer Guidelines revised on 06/14/23, revealed operators should watch the video, read the manual, complete a competency checklist and practice on fellow staff member (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 4 of 6 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 05/28/2024 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)

F 0689 before use with patients. Level of Harm - Actual harm Review of the facility policy titled Lifting Machine, Using a Mechanical (dated 07/2017) revealed at least two staff members are needed to safely move a resident with a mechanical lift and document the transfer. Staff were to be trained and demonstrate competency using the specific machines or devices utilized in the facility. Residents Affected - Few As a result of the incident, the facility took the following actions to correct the deficient practice as of 12/26/23. • On 12/21/23, former STNA #30 was suspended pending investigation upon discovery of the incident and was terminated on 12/22/23. • On 12/21/23, Resident #15 was sent to hospital for evaluation and admitted for a fractured femur which required surgical interventions. Resident #15 was returned to the facility on [DATE]. • On 12/21/23, all 27 residents who were dependent on staff for Hoyer transfers were assessed by Unit Manager/ Assistant Director of Nursing (ADON)/RN #80 with no concerns noted. • On 12/21/23, all 27 residents who were dependent on staff for Hoyer transfers had their care plans reviewed by MDS Coordinator/RN #81 with no concerns noted. • Beginning on 12/21/23, the DON/designee initiated staff competency check offs for STNAs. Any STNA that did not complete a competency check off due to vacations or being off work, did not work until a successful check off was completed. All competency check offs were completed on 12/26/23. Audits of the competency check offs were completed for 26 STNA's with no issues identified. Audit results were reviewed during an ad-hoc Quality Assurance Performance Improvement (QAPI) meeting on 12/26/23. • On 12/21/23, the DON/designee-initiated and completed education to 26 STNAs on reporting changes of condition to the charge nurse, including but not limited to pain and documenting pain. • On 12/21/23, the DON/designee-initiated and completed education to 26 STNAs on proper use of a mechanical lift, including but not limited to number of staff required when transferring a resident. During orientation all new STNA' s hired must complete a Hoyer lift transfer competency before working on the floor and before utilizing a mechanical lift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 5 of 6 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 05/28/2024 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)

F 0689 • Level of Harm - Actual harm On 12/21/23, the DON/designee completed pain assessments and interviewed all 27 residents to determine if residents had any unreported falls or incidents. No issues were identified. Residents Affected - Few • On 12/22/23, the DON/designee reviewed the incident and the self-imposed plan of correction with the IDT. All were in agreement with the plan. • Beginning on 12/26/23, the DON/designee initiated audits for charting of five residents three times a week for four weeks, then monthly for two months to ensure any documentation of pain was reported to the charge nurse. Audit results were reviewed in QAPI on 01/29/24 and then again on 02/27/2024. • Beginning on 12/26/23, the DON/designee began Hoyer lift competency check offs audits five times weekly for four weeks, then monthly for two months. The audit results were reviewed by QAPI on 01/29/24 and then again on 02/27/24. This deficiency represents non-compliance investigated with Complaint Number OH00152927. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365551 If continuation sheet Page 6 of 6