Health inspection·April 4, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Resident Rights, dated 05/30/19, revealed staff would provide care and treatment in a respectful and dignified manner. This deficiency substantiates Complaint Number OH00113136. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 2 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure resident advanced directives included the required signatures and followed the wishes of the residents. This affected three residents (#1, #38, #72) of eighteen residents reviewed for advanced directives. The facility census was 75. Findings included: 1. Review of Resident #72's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #72's diagnoses included congestive heart failure, adult failure to thrive, hypertension, presence of cardiac pacemaker, and depression. Review of Resident #72's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment. Review of Resident #72's plan of care dated [DATE] revealed Resident #72 was a Do Not Resuscitate Comfort Care (DNRCC) code status. The interventions included to obtain medical provider order for code status, obtain copies to have on file, and review the code status quarterly and as needed. Review of Resident #72's electronic medical record physician orders dated [DATE] revealed a Do Not Resuscitate Comfort Care Arrest order (DNRCCA). Review of Resident #72's paper/hard medical chart revealed an undated and unsigned Do Not Resuscitate Ohio Comfort Care (DNR) order. The order included Resident #72's name and date of birth and the name of the physician. The form identified Resident #72 had a DNRCCA code status. Interview on [DATE] at 12:58 P.M. with Regional Director of Clinical Services (RDCS) #656 confirmed Resident #72's DNRCCA did not have the required physician signature. 3. Review of the medical record for Resident #38 revealed an admission date of [DATE] with a diagnosis of spina bifida. Review of the MDS assessment for Resident #38 dated [DATE] revealed Resident #38 was cognitively intact. Review the medical record for Resident #38 revealed there was a red sheet of paper in a sheet protector in the front of her chart that read DNRCC Do Not Resuscitate Comfort Care. Review of the medical record for Resident #38 revealed there was a state DNRCC form dated [DATE] in the front of the chart signed by the physician but it was not signed by the resident. Review of the care plan for Resident #38 dated [DATE] revealed Resident #38 had a DNRCC code status and had the ability to make health care decisions. Review of the nurse progress notes for Resident #38 dated [DATE] through [DATE] revealed the record was silent regarding discussion of code status preference with Resident #38. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 3 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse progress note for Resident #38 dated [DATE] at 4:27 P.M. revealed staff spoke with Resident #38 who confirmed she wanted to be a full code. The physician was notified and Resident #38's code status was changed to full code. Interview on [DATE] at 10:36 A.M. with Resident #38 confirmed she was a full code status and wanted cardiopulmonary resuscitation (CPR) to be initiated in the event her heart stopped. Interview on [DATE] at 4:00 P.M. with Regional Director of Clinical Services (RDCS) #656 confirmed Resident #38's record indicated she was a DNRCC for her code status but was silent for a discussion of Resident #38's preference regarding code status. RDCS #656 further confirmed the DNRCC form was not signed by Resident #38. Review of the facility policy titled General Code Status, dated [DATE], revealed the resident's code status would be noted in the electronic medical records that serve as a source of information to the facility staff for the proper response by the staff for treatment in the event the resident's heart ceases and/or respirations cease, whether by natural or unnatural means. Further review of the policy revealed the resident, and the resident representative would guide decisions regarding code status. 2. Review of the medical record for Resident #1 revealed an admission date of [DATE] with diagnoses including end stage renal disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), systolic heart failure, and chronic ischemic heart disease. Review of the MDS assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of Resident #1's advanced directives revealed Resident #1 signed a State of Ohio Do Not Resuscitate (DNR) form indicating that she wanted to be a DNR Comfort Care. There was no physician's signature or date. Review of Resident #1's physician orders revealed an order entered as DNR. Interview on [DATE] at 2:58 P.M. with RDCS #656 verified Resident #1's DNR form was not completed by a physician and the code status order in the electronic medical record was incorrectly documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 4 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the ombudsman was notified of resident discharges. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 01/11/22. Resident #83 discharged from the facility on 02/15/22 and did not return. Diagnoses included malignant neoplasm of bronchus or lung, atrial flutter, type two diabetes mellitus with hyperglycemia, essential hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had intact cognition. Review of the medical record for Resident #83 revealed no evidence of the ombudsman having been notified of Resident #83's discharge. Interview on 03/30/22 at 3:39 P.M. with Social Worker (SW) #633 revealed he was aware of the need to notify the ombudsman of discharges, however he was unsure who was supposed to complete that notification. SW #633 further verified the ombudsman was not notified of Resident #83's discharge. 3. Review of medical record for Resident #25 revealed an admission date of 01/20/22 with diagnoses including acute pulmonary edema, end stage renal disease, type two diabetes mellitus, severe protein-calorie malnutrition, pressure ulcer or right buttock stage two, pressure ulcer of right heel, stage two, pressure ulcer of left heel stage two, dementia without behavioral disturbance, dependence on renal dialysis, and schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed Resident #25 was cognitively intact. Resident #25 was sent to the hospital on [DATE], 02/25/22, 03/03/22, 03/16/22, and 03/22/22. Review of the medical record for Resident #25 revealed no evidence the Ombudsman was notified of Resident #25's transfers to the hospital on [DATE], 02/25/22, 03/03/22, 03/16/22, and 03/22/22. Interview on 03/31/22 at 11:20 A.M. with SW #633 verified the Ombudsman had not been notified for hospitalizations to his knowledge. 2. Review of the medical record for Resident #50 revealed an admission date of 12/15/21 with diagnoses which included but were not limited to Alzheimer's disease, hypoglycemia, gastrointestinal hemorrhage, adult failure to thrive, respiratory failure, neuromuscular dysfunction of bladder, hypertension, type two diabetes, dysphagia, covid-19, chronic kidney disease, anemia, extended spectrum beta lactamase resistance and dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #50 revealed an impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 5 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's physician orders for the month of February 2022 revealed an order dated 02/12/22 to transfer Resident #50 to the hospital for evaluation. Review of the nurses' progress notes dated 02/12/22 to 02/13/22 for Resident #50 revealed they were silent for evidence that the facility notified the Long Term Care (LTC) Ombudsmen of Resident #50's transfer to the hospital on [DATE]. Interview on 03/31/22 at 11:30 A.M. with SW #633 revealed no one had been notifying the Ombudsman of transfer/discharges. SW #633 verified the LTC Ombudsmen was not notified when Resident #50 was transferred to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 6 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident and/or resident representative was notified of the facility's bed hold policy in writing upon transfer to the hospital. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 01/11/22. Resident #83 discharged from the facility to the hospital on [DATE] and did not return. Resident #83 had diagnoses including malignant neoplasm of bronchus or lung, atrial flutter, type two diabetes mellitus with hyperglycemia, essential hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 had intact cognition. Review of Resident #83's medical record revealed no evidence of Resident #83 nor Resident #83's representative having been notified of the facility bed hold policy in writing upon transferring to the hospital. Review of an email from the Administrator dated 03/30/22 at 11:49 A.M. confirmed there were no notifications made regarding bed hold for Resident #83 upon transfer to the hospital. 3. Review of medical record for Resident #25 revealed an admission date of 01/20/22 with diagnoses including acute pulmonary edema, end stage renal disease, type two diabetes mellitus (DM2), severe protein-calorie malnutrition, pressure ulcer or right buttock stage two, pressure ulcer of right heel, stage two, pressure ulcer of left heel stage two, dementia without behavioral disturbance, dependence on renal dialysis, and schizoaffective disorder. Review of Resident #25's MDS assessment dated [DATE] revealed Resident #25 was cognitively intact and was sent to the hospital on [DATE], 02/25/22, 03/03/22, 03/16/22, and 03/22/22. Interview on 03/31/22 at 11:35 A.M. with Registered Nurse (RN) #656 verified no bed hold notices were sent with residents when they were sent to the hospital. 2. Review of the medical record for Resident #50 revealed an admission date of 12/15/21 with diagnoses which included but were not limited to Alzheimer's disease, hypoglycemia, gastrointestinal hemorrhage, adult failure to thrive, respiratory failure, neuromuscular dysfunction of bladder, hypertension, type two diabetes, dysphagia, covid-19, chronic kidney disease, anemia, extended spectrum beta lactamase resistance and dysphagia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had impaired cognition. Review of Resident #50's physician orders for the month of February 2022 revealed an order dated 02/12/22 for Resident #50 to go to the hospital for evaluation of health care status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 7 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #50's progress notes dated 02/12/22 through 02/28/22 revealed they were silent regarding the facility providing written information to the resident and/or resident representative regarding the bed hold policy. Interview on 03/30/22 at 2:10 P.M. with Social Worker (SW) #633 revealed nurses are supposed to complete the bed hold notification for residents who leave in a emergency situation. Interview on 03/31/22 at 3:20 P.M. with the Regional Director of Clinical Services #656 verified a bed hold notification was not given to Resident #50 as it should have been when Resident #50 was sent to the hospital on [DATE]. Review of facility policy titled Bed Hold Policy and Procedure, undated, revealed the Admissions Director or designee will notify the resident and/or responsible party of the days available under their Medicaid benefits or the private pay cost associated with holding the bed will be explained, within 24 hours of the patient leaving the facility, or the following business day if the patient leaves on the weekend or a holiday. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 8 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observations and review of the facility policy, the facility failed to conduct care planning conferences. This affected one (Resident #10) of three residents reviewed for care planning. The facility census is 75. Findings included: Medical record review for Resident #10 revealed an admission on [DATE] with diagnoses which included but were not limited to post traumatic osteoarthritis, hypertension, and overactive bladder. Review of Resident #10's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 had intact cognition. Review of the progress notes for Resident #10 dated 12/25/21 to 03/30/22 revealed they were silent for any documentation the resident and/or resident representative was given advance notice for a care conference appointment. Further review of progress notes for Resident #10 revealed they were silent for a care conference meeting. Interview with Social Worker (SW) #633 on 03/29/22 at 10:25 A.M. verified no care conferences have been planned or conducted for Resident #10 since admission. Review of facility policy titled Plan of Care Overview, undated, revealed the facility will review the plan of care and schedule meetings with the resident or resident representative to colborate care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 9 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #70 revealed an admission date of 01/20/22. Diagnoses included adult failure to thrive, cognitive communication deficit, need for assistance with personal care, and weakness. Residents Affected - Few Review of the Resident #70's quarterly MDS asssessment revealed Resident #70 had severely impaired cognition and did not exhibit any behaviors during the assessment period. Review of Resident #70's care plan dated 03/11/22 revealed the resident had an ADL self-care performance deficit related to adult failure to thrive. Interventions included to provide limited assistance with grooming, bathing, and hygiene. Observation on 03/28/22 at 9:24 A.M. revealed Resident #70 resting in bed. Resident #70's fingernails were observed to extend approximately half of an inch beyond the finger tip. Concurrent interview with Resident #70 revealed he wanted his fingernails cut. Observation on 03/29/22 at 8:34 A.M. revealed Resident #70 walking on the unit with a walker. The resident's fingernails were observed to still be long. Observation on 03/30/22 at 9:24 A.M. revealed Resident #70 resting in bed awake. Resident #70's fingernails remained uncut. Concurrent interview with Resident #70 revaled he wanted his fingernails cut. Interview on 03/30/22 at 9:24 A.M., with Certified Nursing Assistant (CNA) #607 verified Resident #70's finger nails were long and did not appear to have been trimmed anytime recently. CNA #607 stated resident fingernails are to be cut/trimmed on shower days and stated Resident #70 was not known to resist care. Observation on 03/31/22 at 8:47 A.M. revealed Resident #70 was ambulating in his room. Resident #70's finger nails remained long and untrimmed. 3. Review of the medical record for Resident #38 revealed an admission date of 02/01/22 with a diagnosis of spina bifida. Review of Resident #38's MDS assessment dated [DATE] revealed Resident #38 was cognitively intact and was totally dependent on assistance of staff for bed mobility, transfers, and hygiene. Review of the care plan for Resident #38 dated 02/22/22 revealed Resident #38 had an ADL self-care performance deficit related to diagnosis of spina bifida. Review of Resident #38's facility bathing records for 02/28/22 through 03/28/22 revealed the facility had no record of bathing provided to Resident #38 during this time frame. The facility also had no records of refusals of bathing from Resident #38. Observation on 03/28/22 at 10:36 A.M. of Resident #38 revealed Resident #38's hair appeared unwashed and Resident #38's fingernails were painted with nail polish and approximately half of the polish had chipped and worn off. A few of the Resident #38's fingernails were jagged and uneven on the ends. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 10 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0677 Level of Harm - Minimal harm or potential for actual harm Interview on 03/28/22 at 10:36 A.M. with Resident #38 confirmed staff gave her bed baths most of the time but they had not washed her hair in at least three weeks. Resident #38 confirmed the last time staff washed her hair they transferred her into her wheelchair and took her to a large bathroom and washed her hair at the sink. Resident #38 further confirmed staff had painted and trimmed her nails approximately a month ago and no one had offered to provide nail care since then. Residents Affected - Few Interview on 03/28/22 at 10:46 A.M. with Licensed Practical Nurse (LPN) #636 confirmed Resident #38's hair appeared unwashed and her nails had chipped polish with several of the nails appearing jagged and in need of a trim. Interview on 03/31/22 at 9:47 A.M. with Regional Director of Clinical Services (RDCS) #656 confirmed the facility had no records of baths or nail care for Resident #38, or Resident #38's hair being washed. Review of the facility policy titled Nail and Hair Hygiene Services, dated 05/30/19, revealed hair shampooing would be completed on an as-needed basis but no less than weekly. Routine care also included nail hygiene services including routine trimming, cleaning and filing. Routine nail hygiene and hair hygiene could be performed in conjunction with bathing or performed separately. This deficiency represents ongoing noncompliance from the survey dated 03/02/22. Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected three residents (#38, #50, and #70) of three residents reviewed for ADLs. The census was 75. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 12/15/21 with diagnoses which included but were not limited to Alzheimer's disease, adult failure to thrive, respiratory failure, neuromuscular dysfunction of bladder, and dysphagia. Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition. Resident #50 had no behaviors coded during the assessment period. Resident #50 required total assistance with two staff members for bed mobility, transfers, eating, and toileting. Review of the plan of care for Resident #50 dated 01/07/22 with revisions on 03/02/22 revealed Resident #50 had an activity of daily living (ADL) deficit and required assistance. Interventions included total assistance with hygiene. Review of the nurse progress notes for Resident #50 dated 02/19/22 through 03/30/22 revealed the notes were silent regarding refusal of shower and/or refusal of resident to have his nails cleaned. Review of Resident #50's bathing records for the month of March 2022 revealed the records were silent regarding trimming and cleaning of Resident #50's nails. Observation on 03/28/22 at 9:58 A.M. revealed Resident #50 was laying in bed with hands crossed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 11 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete above the sheets. Resident #50's fingernails were observed to extend approximately half of an inch beyond the finger tip with jagged edges. All of the nails had a unknown black material under the nail. Interview on 03/28/22 at 10:06 A.M. with Regional Director of Clinical Services (RDCS) #656 verified all of Resident #50's nails on both hands had an unknown black material under the nails. The interview further revealed nail care should be completed on shower days by the State Tested Nurse Aide (STNA). Event ID: Facility ID: 365562 If continuation sheet Page 12 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to complete weekly skin assessments as ordered by the physician. This affected two (Resident #36 and #75) of nineteen residents reviewed for skin assessments. The facility census was 75. Residents Affected - Few 1. Review of the medical record for Resident #36 revealed an admission date of 01/04/19. Resident #36's medical diagnoses included cerebral palsy, diabetes mellitus, respiratory failure, history of traumatic brain injury, mood disorder, and major depressive disorder. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitive impaired. Resident #36 required total two-person physical assist for bed mobility, transfers, toilet use, and personal hygiene, and required total dependence one-person physical assist for dressing and bathing. Review of Resident #36's plan of care dated 02/20/22 revealed Resident #36 was at risk for developing a pressure ulcer related to deconditioned and muscle weakness, limited mobility, limited range of motion, contractures of bilateral hands, decreased range of motion to bilateral lower extremities, bowel and bladder incontinence, cognitive and communication impairment; all secondary to cerebral palsy, history of traumatic brain injury, and being dependent of staff. History of pressure ulcers to left foot, heels, sacrum, and dry skin to bilateral upper and lower extremities. Interventions included weekly skin assessment, assist to shift weight in geri-chair, routinely administer treatments as ordered and monitor for effectiveness, and assist resident to turn and reposition every two hours and as needed. Review of Resident #36's physician order dated 01/04/19 revealed to complete a weekly skin assessment every Monday on night shift. Review of weekly skin assessments for Resident #36 revealed skin assessments were not completed on 11/15/21, 11/29/21, 12/13/21, 12/27/21, 01/10/22, 01/24/22, 01/31/22, 02/07/22, 02/21/22, 02/28/22, 03/07/22, 03/14/22, 03/21/22, and 03/28/22. Interview on 03/29/22 at 9:25 A.M. with Regional Director of Clinical Services (RDCS) #656 revealed the weekly skin observation or weekly skin assessment should have been done weekly and should be in Resident #36's electronic chart. RDCS #656 verified skin assessments were missing in Resident #36's chart. 2. Review of Resident #75's medical record revealed an admission date of 02/18/22 with diagnoses of local infection of the skin and subcutaneous tissue, acute kidney failure, diabetes mellitus type two with foot ulcer, schizoaffective disorder, and acute on chronic diastolic heart failure. Review of Resident #75's MDS assessment dated [DATE] revealed Resident #75 was cognitively intact and required extensive to total dependence of for all activities of daily living, except eating, which she required setup and supervision. Review of Resident #75's physician orders dated 02/18/22 revealed to complete weekly skin assessments and documentation was to be completed on the Weekly Skin Assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 13 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0684 Level of Harm - Minimal harm or potential for actual harm Review of Resident #75's Weekly Skin Check Assessments revealed only one assessment was completed and it was completed on 03/11/22. Interview on 03/31/22 at 11:35 A.M. with Registered Nurse (RN) #656 verified the Weekly Skin Assessments were not completed for Resident #75. Residents Affected - Few This deficiency substantiates Complaint Number OH00113136. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 14 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, resident interview, and staff interview, the facility failed to arrange for vision and hearing services. This affected one (Resident #51) of three residents reviewed for communication and sensory needs. The census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #51 revealed an admission date of 11/26/21 with diagnoses including end stage renal disease (ESRD) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 02/16/22 revealed Resident #51 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Further review of the MDS for Resident #51 revealed it was coded negative for Resident #51 wearing eyeglasses. Review of the March 2022 monthly physician orders for Resident #51 dated 02/02/22 revealed an order for Resident #51 to have an optometry or ophthalmology consult. Observation on 03/28/22 at 2:42 P.M. of Resident #51 revealed Resident #51 was wearing prescription glasses. Interview on 03/28/22 at 2:42 P.M. with Resident #51 confirmed he had prescription glasses when he was admitted to the facility, and it had been years since he had an eye exam. Resident #51 further confirmed he felt his vision was deteriorating and he thought his eyeglasses needed to be adjusted to better correct his vision Interview on 03/30/22 at 3:38 P.M. with Social Worker (SW) #633 confirmed Resident #51 did have a consent for optometry or ophthalmology services and the facility had a contract with a mobile provider for vision services but they had not arranged for Resident #51 to be seen. Review of the contract between mobile care provider and the facility dated and signed 07/01/21 revealed the provider offered optometry services and other on-site ancillary services to improve the quality of care and the quality of living for the residents of the facility. Further review of the contract revealed the facility would be responsible for providing information on residents requiring services and would obtain physician orders for needed services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 15 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on medical record review, observation, resident interview, and staff interview, the facility failed to order and implement a hand splint as documented for a resident with impaired range of motion. This affected one (Resident #38) of two residents reviewed for positioning and mobility. The census was 75. Findings include: Review of the medical record for Resident #38 revealed an original admission date of 09/10/20 with a diagnosis of spina bifida. Review of the Minimum Data Set (MDS) for Resident #38 dated 02/16/22 revealed Resident #38 was cognitively intact and was totally dependent on assistance of staff with bed mobility, transfer, and hygiene. Review of the care plan for Resident #38 dated 02/22/22 revealed it was silent regarding the use of a hand splint. Review of the nurse progress notes for Resident #38 dated 07/01/21 through 03/28/22 revealed the notes were silent regarding the use of a hand splint for Resident #38. Review of the Resident #38's Treatment Administration Record (TAR) for March 2022 revealed it did not include the use of a hand splint. Review of an occupational therapy (OT) evaluation for Resident #38 dated 10/26/21 revealed Resident #38 was not picked up for therapy due to functioning at baseline and skilled OT services were not indicated. Further review revealed the Resident #38's range of motion (ROM) to the left upper extremity was impaired. Review of the OT evaluation for Resident #38 dated 10/26/21 revealed a hand splint was found in Resident #38's room and there were no orders for carryover regarding the use of the splint. Further review of the evaluation revealed Resident #38 had documented physical impairments and associated functional deficits and was at risk for contracture(s) and decreased skin integrity. The evaluation further revealed OT would obtain a new order for the splint to be worn to Resident #38's left hand as needed for left hand pain support. Observation of Resident #38 on 03/28/22 at 10:55 A.M. revealed Resident #38 was in bed and had a left-hand splint in her room which was out of her reach. Interview with Resident #38 on 03/28/22 at 10:55 A.M. confirmed Resident #38 had a left-hand splint in her room which was given to her by therapy to help prevent her contracture. Resident #38 confirmed she was unable to don and doff the splint by herself and no one had offered to put the splint on her for at least a month. Interview on 03/28/22 at 11:00 A.M. with Licensed Practical Nurse (LPN) #636 confirmed there was a hand splint in Resident #38's room, but the facility had no orders for it, nor did they have a wearing schedule and/or information regarding the splint. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 16 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0688 Level of Harm - Minimal harm or potential for actual harm Interview on 03/30/22 at 10:34 A.M. with Physical Therapist (PT) #660 revealed the facility had changed ownership in July 2021 and she thought Resident #38 had received the hand splint from the prior therapy company but there were no orders or instructions for carryover. PT #660 further revealed the therapy staff would evaluate Resident #38 for the use of the splint. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 17 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #72's medical record revealed an original admission date of 12/15/18 and a readmission date of 03/22/20. Resident #72's admission diagnoses included congestive heart failure, adult failure to thrive, hypertension, presence of cardiac pacemaker, and depression. Review of Resident #72's MDS assessment dated [DATE] revealed Resident #72 had severe cognitive impairment. The MDS revealed Resident #72 required extensive one-person assistance for transfers, bed mobility, dressing, toileting, and personal hygiene. Review of Resident #72's plan of care dated 03/25/22 revealed the resident was at risk for falls related to weakness and congestive heart failure. Interventions included anti-roll back on chairs, anticipate the resident's needs, assist with repositioning, assist with toileting, assure proper positioning, encourage toileting in advance of need, pressure sensitive alarm in chair (initiated on 03/23/22), and proactively promote comfort. Review of Resident #72's progress note dated 02/25/22 entered by Registered Nurse (RN) #636 revealed Resident #72 was noted in the restroom trying to transfer herself from the wheelchair to the toilet resulting in a fall. The nurse heard Resident #72 yelling for help and when the writer entered the restroom, Resident #72 was on the bathroom floor lying on her right side with right arm under her upper torso and left arm across her left side and both legs bent in a slight fetal position. Resident #72 was assessed by RN #636 and had some skin tears to the right hand and had reopened an old area to the right side of her forehead. Observation on 03/29/22 at 1:28 P.M. revealed Resident #72 sitting up in her wheelchair by the nursing station. Resident #72 was observed with a four by four bandage across the right forehead. Observation of the resident sitting in her wheelchair did not reveal a chair alarm. Interview on 03/29/22 at 1:29 P.M. with State Assisted Nursing Assistant (STNA) #651 and RN #636 confirmed Resident #72 did not have the alarm in her wheelchair as per the resident's plan of care. Interview on 03/29/22 at 2:30 P.M. with the Regional Director of Clinical Services (RDCS) #656 revealed Resident #72 was sitting in her wheelchair on 02/25/22 when she stood and attempted to take herself to the bathroom and fell. RDCS #656 confirmed the new intervention was a sensitive alarm in chair and was initiated on 03/23/22. Review of the facility policy titled, Fall Prevention and Management, dated 05/25/21, revealed the Interdisciplinary Team should review the fall and interventions should be put into place. This deficiency substantiates Complaint Number OH00110788. Based on record review, observation, staff interview, and review of facility policy the facility failed to ensure fall prevention interventions were implemented according to evaluations and the care plan. This affected two (Resident #41 and #72) of five residents reviewed for accidents. The census was 75. Findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 18 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #41 revealed an admission date of 05/13/21 with a diagnosis of acute respiratory failure (ARF). Review of the Minimum Data Set (MDS) for Resident #41 dated 02/09/22 revealed Resident #41 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL). Residents Affected - Few Review of the care plan for Resident #41 dated 02/22/22 revealed Resident #41 was at risk for falls related to diagnoses including, vascular dementia with behaviors, metabolic encephalopathy, depression, schizophrenia, and epilepsy. Interventions included anticipate Resident #41's needs and assist with positioning. Review of occupational therapy (OT) evaluation for Resident #41 dated 02/14/22 revealed Resident #41 had a custom wheelchair and the therapist trained staff on the use of brakes, tilt in space feature, and the use of leg rests in order to maximize Resident #41's safety within the facility and reduce risk for falls. Observation on 03/28/22 at 12:56 P.M. revealed State Tested Nursing Assistant (STNA) #657 pushed Resident #41 in his wheelchair from the common area down the hall to his room. The wheelchair's footrests were not on the wheelchair. As Resident #41 was being propelled down the hall, STNA #657 directed Resident #41 several times to hold his feet up, but Resident #41 repeatedly planted his feet on the floor and at one point almost fell forward out of chair. Further observation revealed STNA #657 found Resident #41's wheelchair footrests in his room, put them on the wheelchair, and positioned Resident #41's feet on top of the footrests after discussion with the state surveyor. Interview on 03/28/22 at 12:58 P.M. with STNA #657 revealed this was her first time in the facility and she didn't know the residents. STNA #657 confirmed she told Resident #41 to lift his feet up while she propelled him down the hall in his wheelchair because she was afraid of him falling forward out of wheelchair. STNA #657 further confirmed she didn't think of putting footrests on the wheelchair until after discussion with the state surveyor. Interview on 03/30/22 at 9:49 P.M. with Physical Therapist (PT) #660 confirmed Resident #41 should have footrests placed on his wheelchair for safety to prevent falls and injury when he is being wheeled down the hallway. Review of facility policy titled Fall Prevention and Management, dated 05/25/21, revealed the facility would assess residents at risk for falls and therapy would screen the resident to assist with identification of potential ADL issues and to also assist with identification of how a resident can transfer and make recommendations for equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 19 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #21 revealed an admission date of 11/02/21 with diagnoses including but not limited to open wound right and left lower leg, obesity, necrotizing fasciitis, depression, obstructive sleep apnea, mental disorder, and osteoarthritis. Residents Affected - Few Review of the quarterly MDS dated [DATE] for Resident #21 revealed an intact cognition. Resident #21 required extensive assistance for bed mobility, transfers, and toileting. Review of the plan of care dated 11/19/21 for Resident #21 revealed it was silent for the use of a CPAP machine. Review of active physician orders for Resident #21 revealed they were silent for orders related to the use of a CPAP machine. Review of progress notes for Resident #21 dated 11/12/21 revealed Resident #32's medical record was reviewed for the comprehensive MDS. The documentation revealed diagnoses included obstructive sleep apnea. Review of the after visit summary from the hospital dated 11/07/21 through 11/11/21 revealed Resident #21 was treated for wounds to the leg, surgical interventions, and antibiotic treatment. The document reflected the diagnosis of obstructive sleep apnea. The after visit summary identified the use of a CPAP when sleeping and the device was from home. Observation on 03/28/22 at 10:11 A.M. revealed Resident #21 laying in bed with a CPAP machine sitting on the stand beside the bed. Interview on 03/28/22 at 10:11 A.M. with Resident #21 revealed the CPAP was brought to the facility from the hospital. Resident #21 stated she has been using it for about three years. Resident #21 further stated she had not used it since her arrival at the facility in November. Resident #21 stated staff here do not offer it to her or assist her with application. Interview on 03/29/22 at 2:55 P.M. with Registered Nurse #901 verified there were no current orders for a CPAP for Resident #21. Interview on 03/30/22 at 2:45 P.M. with Regional Director of Clinical Services (RDCS) #656 verified Resident #21 did not have any orders for a CPAP machine. The interview further revealed the physician had been notified for orders and they have been added to her medical record. Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident oxygen tubing was dated as well as ensure handheld nebulizer (HHN) machines and continuous positive airway pressure (CPAP) machines in resident rooms had physician orders for use. This affected two (Residents #21 and #40) of two residents reviewed for respiratory care. The census was 75. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 20 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0695 diagnosis of malignant neoplasm of the lung. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Residents Affected - Few Review of the March 2022 monthly physician orders for Resident #40 revealed an order dated 01/06/22 for resident to receive oxygen two liters per minute (LPM) continuously per nasal cannula (NC) as well as an order dated 03/29/22 to change oxygen tubing every week and as needed. There were no physician orders for an HHN. Review of the care plan for Resident #40 dated 01/26/22 revealed Resident #40 had an alteration in respiratory status due to nocturnal hypoxia. Interventions included oxygen therapy as ordered and change tubing per facility policy. Review of the care plan revealed it was silent regarding the use of an HHN. Observation on 03/29/22 at 10:22 A.M. of Resident #40 revealed Resident #40 was receiving oxygen at two LPM per NC. The oxygen tubing was not dated. Further observation revealed there was a HHN machine with undated tubing and mask attached. Interview on 03/29/22 at 10:22 A.M. of Resident #40 confirmed her oxygen tubing was supposed to be changed once per week but it hadn't been changed in several weeks. Resident #40 further confirmed the HHN machine with undated tubing was not hers and it had been in the room when she moved into the facility. Interview on 03/29/22 at 10:33 A.M. with Licensed Practical Nurse (LPN) #636 confirmed Resident #40's oxygen tubing was not dated and she was unsure when it had been changed last. LPN #636 further confirmed Resident #40 did not have an order for an HHN machine and she thought the device was in the room from the previous resident who lived there. Review of the facility policy titled Oxygen-Medical Gas Use, dated 05/30/19, revealed oxygen therapy will be provided to residents in a safe manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 21 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received effective pain management and staff adequately assessed residents for pain. This affected one (Resident #40) of five residents reviewed for unnecessary medications. The census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a diagnosis of diabetes mellitus. Review of the Minimum Data Set for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Review of the care plan for Resident #40 dated 02/22/22 revealed Resident #40 had complaints of acute/chronic pain. Interventions included to provide medication per orders, monitor for side effects, evaluate effectiveness of medication, and observe for pain every shift. Review of the March 2022 monthly physician order for Resident #40 revealed an order dated 01/07/22 for Norco four times per day routinely for pain. Review of the March 2022 Medication Administration Record (MAR) for Resident #40 revealed Resident #40 did not receive Norco from 03/19/22 through 03/24/22 for a total of 24 missed doses. Review of the MAR revealed on the dates and times in which Resident #40 received Norco there was a pain level documented, prior to administration, of zero to 10 with zero being the absence of pain and 10 being the worse pain possible. The MAR did not have a pain level documented for 03/19/22 through 03/24/22. Further review of the MAR revealed Resident #40 had an order for as needed Tylenol to be given for pain. Review of controlled substance sheet for Norco for Resident #40 revealed Resident #40 did not receive Norco from 03/19/22 through 03/24/22 for a total of 24 missed doses. Review of the nurse progress notes for Resident #40 dated 03/19/22 through 03/24/22 revealed the notes were silent regarding Resident #40's pain level, nonpharmacological interventions provided to assist while the resident was out of pain medication, or other pain medications offered. The notes revealed Resident #40's Norco was not available for administration. Interview on 03/28/22 at 9:52 A.M. with Resident #40 confirmed she had chronic back pain and she had received pain medication as ordered except for earlier in the month when they ran out of her Norco. Resident #40 confirmed nurses did not assess her for pain except when they were getting ready to give her a Norco. Resident #40 stated she received as needed Tylenol during the time frame when her Norco was unavailable and her pain was tolerable. Interview on 03/31/22 at 4:30 P.M. with Regional Director of Clinical Services (RDCS) #656 confirmed Resident #40 did not receive Norco for pain as ordered by the physician from 03/19/22 through 03/24/22 and her medical record did not include assessment of resident's pain during this time frame. Review of the facility policy titled Pain Management and Assessment, dated 05/29/19, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 22 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0697 Level of Harm - Minimal harm or potential for actual harm facility would ensure staff assessed and documented resident pain levels and non-pharmacologic measures attempted and the resident response. This deficiency substantiates Complaint Number OH00113136. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 23 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. Resident #82 discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: amlodipine besylate (antihypertensive) daily at 8:00 A.M., atorvastatin calcium (antihyperlipidemic) daily at 9:00 P.M., clopidogrel bisulfate (anticoagulant) daily at 6:00 P.M., insulin glargine (antidiabetic) daily at 6:00 P.M., lorazepam (antianxiety) daily at 8:00 A.M., losartan potassium (antihypertensive) daily at 8:00 A.M., metoprolol succinate (antihypertensive) daily at 8:00 A.M., trazodone (antidepressant) at 6:00 P.M., clonidine (antihypertensive) twice daily at 7:30 A.M. and 4:00 P.M., metformin (antidiabetic) twice daily at 7:30 A.M. and 4:00 P.M., pantoprazole (a drug used to relieve heartburn) twice daily at 7:30 A.M. and 4:00 P.M perphenazine (antipsychotic) twice daily at 7:30 A.M. and 4:00 P.M., and insulin lispro (antidiabetic) three times daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Further review of the MAR revealed none of the medications listed were administered at any time while the resident was in the facility. Review of progress notes dated 03/04/22 at 3:57 P.M. through 03/05/22 at 8:36 A.M. revealed no documentation regarding Resident #82's medications not being administered. Review of progress notes dated 03/05/22 at 9:28 A.M. through 9:31 A.M. revealed Resident #82's medications were not administered due to awaiting pharmacy. Interview on 03/30/22 at 11:03 A.M., with RDCS #656 verified there was no evidence of Resident #82's medications being administered. RDCS #656 further stated the medications should have been pulled from the the emergency medication supply. Review of the facility policy titled, Medication Administration, dated 12/14/17, revealed medication was to be administered as prescribed by the provider. Further review of the policy revealed medications that are withheld or not given will be documented. 3. Review of the March 2022 monthly physician orders for Resident #40 revealed an order dated 01/07/22 for Norco four times per day routinely for pain. Review of the nurse progress notes for Resident #40 dated 03/19/22 through 03/24/22 revealed Norco was not available for administration. Review of the March 2022 Medication Administration Record (MAR) for Resident #20 revealed resident did not receive Norco from 03/19/22 through 03/24/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 24 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0755 Level of Harm - Minimal harm or potential for actual harm Review of controlled substance sheet for Norco for Resident #40 revealed resident did not receive Norco from 03/19/22 through 03/24/22 Interview on 03/28/22 at 9:52 A.M. with Resident #40 confirmed she had chronic back pain and she had received pain medication as ordered except for earlier in the month when they ran out of her medication. Residents Affected - Few Interview on 03/31/22 at 4:30 P.M. with Regional Director of Clinical Services (RDCS) #656 confirmed Resident #40 did not receive Norco for pain as ordered by the physician from 03/19/22 through 03/24/22. 2. Medical record review for Resident #10 revealed an admission date of 12/25/21 with diagnoses that included but were not limited to post traumatic osteoarthritis, hypertension and overactive bladder. Review of the comprehensive MDS assessment for Resident #10 revealed Resident #10 had intact cognition. Review of the plan of care for Resident #10 dated 01/09/22 revealed Resident #10 had complaints of acute and chronic pain related to osteoarthitis. Interventions included administer non pharmacologial interventions, complete pain assessment with readmission and quarterly, observe for pain every shift, and provide pain medications as ordered. Review of the physician's orders for Resident #10 revealed an order dated 03/02/22 for lidocaine patch 1.8 percent apply to right knee topically every 12 hours for pain, on in morning and off at bedtime. Review of the Medication Administration Record (MAR) for the month of March for Resident #10 revealed the resident did not recieve the lidocaine patches on 03/03/22, 03/04/22, 03/28/22, 03/29/22, and 03/30/22. Observation on 03/28/22 at 9:54 A.M. of Resident #10 revealed the resident ambulated to the doorway and asked for a patch for the knee. Interview on 03/28/22 at 11:15 A.M. with Licensed Practical Nurse (LPN) #902 verified the lidocaine patches were not available and were ordered from the pharmacy. Interview on 03/29/22 at 2:19 P.M. with RN #901 verified the lidocaine patches for Resident #10 were ordered from the pharmacy. RN #901 verified the lidocaine patches were not in the residents room for self administration. Interview on 03/30/22 at 11:25 A.M. with Registered Nurse (RN) #903 verified the lidocaine patch was not available for administration and was ordered from the pharmacy. Interview on 03/31/22 at 4:43 P.M. with Regional Director of Clinical Services (RDCS) #656 verified the lidocaine patches were not applied for the last three days for Resident #10 according to the medication administration record. Based on observation, medical record review, and staff interview, the facility failed to ensure (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 25 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lidocaine patches (local anesthetic medication) were available for administration. This affected two residents (#10 and #40) of seven residents (#10, #14, #37, #31, #40, #43, and #79) who receive Lidocaine patches at the facility. Additionally, the facility failed to ensure Norco (pain medication) was available for administration. This affected one resident (#40) of five residents (#40, #25, #68, #19, and #30) who received Norco at the facility. Finally, the facility failed to ensure resident medications were available upon admission to the facility. This affected one (#82) of one resident reviewed for discharge. The facility census was 75. Findings included: Review of Resident #40's medical record revealed an admission date of 01/05/22. admission diagnoses included sepsis, morbid obesity, diabetes, chronic atrial fibrillation, anxiety, intervertebral disc degeneration, and malignant neoplasm of unspecified part of left lung. Review of Resident #40s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had cognitive impairment. Further review of the MDS revealed the resident received scheduled pain medications and as-needed pain medications or occasional pain. Review of Resident #40's plan of care dated 03/25/22 revealed the resident had complaints of acute and chronic pain related to cervical and lumbar disc degeneration, and adenocarcinoma. Interventions included to provide pain medications as ordered. Review of Resident #40's physician orders dated 01/05/22 revealed an order for Aspercreme Lidocaine Patch four percent to be applied to back topically every morning at 9:00 A.M. and removed every evening at 9:00 P.M. Observation on 03/30/22 at 8:04 A.M. of the facility's medication administration pass with Agency Registered Nurse (RN) #699 revealed Resident #40's aspercreme lidocaine four percent patch was unavailable for administration. Review of Resident #40's Medication Administration Record (MAR) for 03/30/22 indicated to see nurse's note. Review of Resident #40's progress note entered by RN #699 dated 03/30/22 at 11:31 A.M. revealed the Resident #40's Aspercreme Lidocaine four percent was on backorder and was not available. Interview on 03/30/22 at 11:33 A.M. with RN #699 confirmed Resident #40 did not receive her Aspercreme Lidocaine four percent patch as ordered. RN #699 confirmed the medication was backordered and was not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 26 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure appropriate indications for the use of antipsychotic medications as well as complete appropriate monitoring after starting an antipsychotic medication. This affected two (#08 and #36) of five residents reviewed for unnecessary medications. The facility census was 75. Findings include: 1. Review of the medical record of Resident #08 revealed an admission date of 04/26/20. Diagnoses included type two diabetes mellitus, acute kidney failure, neuromuscular dysfunction of bladder, major depressive disorder, insomina, peripheral vascular diseases, generalized anxiety disorder, alzheimer's disease, dementia without behavioral disturbance, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had severely impaired cognition. The resident did not exhibit behaviors during the assessment period. Review of Resident #08's physician orders revealed an order dated 04/02/21 for Seroquel (an antipsychotic medication) 25 milligrams (mg) daily for agitation. Interview on 03/30/22 at 4:32 P.M., with the Director of Nursing (DON) confirmed agitation was not an appropriate diagnosis for the use of Seroquel. 2. Review of the medical record of Resident #36 revealed an admission date of 01/10/22. Diagnoses included dementia without behavioral disturbance, disorientation, type two diabetes mellitus, unspecified mood (affective) disorder, unspecified disorder of adult personality and behavior, chronic atrial fibrillation, hyperlipidemia, and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #36 had severely impaired cognition. Resident #36 exhibited delusions and other behavior symptoms not directed towards others one to three days during the assessment period. Review of Resident #36's physician orders revealed an order dated 01/13/22 for Risperdal (antipsychotic medication) 0.5 mg twice per day for anxiety. Review of the plan of care dated 01/30/22 revealed the resident utilized anti-psychotic medication. Interventions included to complete AIMS (Abnormal Involuntary Movement Scale) test per company process. Review of the medical record revealed no evidence of an AIMS being completed for Resident #36. Interview on 03/30/22 at 4:32 P.M., with the DON verified anxiety was not an appropriate indication for the administration of Risperdal. The DON further verified there had not been an AIMS completed since Resident #36 started taking Risperdal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 27 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 03/31/22 at 10:29 A.M., with Regional Director of Clinical Services #656 revealed there was no written policy for conducting AIMS, however the consulting pharmacist informed her that an AIMS should be completed within 1-2 weeks of starting a new antipsychotic medication. Review of the facility policy titled, Antipsychotic Second Clinical Review, dated 03/01/19, revealed residents will not receive antipsychotic medications which are not clinically indicated to treat a specific condition. Event ID: Facility ID: 365562 If continuation sheet Page 28 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record of Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. The resident discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Residents Affected - Few Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: insulin glargine daily at 6:00 P.M., and insulin lispro three times daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Further review of the MAR revealed none of the medications listed were administered. Review of Resident #82's progress notes dated 03/04/22 at 3:57 P.M. through 03/05/22 at 8:36 A.M. revealed no documentation regarding medications not being administered. Review of Resident #82's progress notes dated 03/05/22 at 9:28 A.M. through 9:31 A.M. revealed medications were not administered due to awaiting pharmacy. Interview on 03/30/22 at 11:03 A.M., with Regional Director of Clinical Services (RDCS) #656 verified there was no evidence of Resident #82's medications having been provided. RDCS #656 further stated the medications should have been pulled from the the emergency medication supply. Based on record review, staff interview, and review of facility policy the facility failed to residents were free from significant medication errors. This affected two (Residents #40 and #82) of 14 facility-identified residents with orders for insulin. Additionally, this affected one (Resident #50) out of 75 residents in the facility who did not have a contraindication or allergy and could potentially receive tuberculin testing solution. The census was 75. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a diagnosis of diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Review of the care plan for Resident #40 dated 01/26/22 revealed Resident #40 had DM. Interventions included to observe for signs and symptoms of hypo/hyperglycemia and administer insulin as ordered. Review of the March 2022 monthly physician orders for Resident #40 revealed an order dated 01/05/22 for Resident #40 to receive insulin routinely at bedtime for treatment of DM. The order did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 29 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0760 include parameters for withholding the medication. Level of Harm - Minimal harm or potential for actual harm Review of nurse progress notes for Resident #40 dated 03/06/22 revealed Resident #40's blood sugar was 145 and insulin dose at bedtime was withheld per nursing judgment. Residents Affected - Few Review of nurse progress notes for Resident #40 dated 03/10/22 revealed Resident #40's blood sugar was 177 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/11/22 revealed Resident #40's blood sugar was 136 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/14/22 revealed Resident #40's blood sugar was 159 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/15/22 revealed Resident #40's blood sugar was 138 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/16/22 revealed Resident #40's blood sugar was 147 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/24/22 revealed Resident #40's blood sugar was 110 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/25/22 revealed Resident #40's blood sugar was 118 and insulin dose at bedtime was withheld per nursing judgment. Review of nurse progress notes for Resident #40 dated 03/28/22 revealed Resident #40's blood sugar was 113 and insulin dose at bedtime was withheld per nursing judgment. Interview on 03/31/22 at 4:30 P.M. with Regional Director of Clinical Services (RDCS) #656 confirmed Resident #40's evening dose of long-acting insulin was withheld on the following dates without parameters, a physician order, or notification from the physician to do so: 03/06/22, 03/10/22, 03/11/22, 03/14/22, 03/16/22, 03/24/22, 03/25/22, 03/28/22. 3. Medical record review for Resident #50 revealed an admission on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, adult failure to thrive, respiratory failure, neuromuscular dysfunction of bladder, type two diabetes, and dysphagia. Review of the quarterly MDS assessment dated [DATE] for Resident #50 revealed Resident #50 had impaired cognition. Review of the plan of care for Resident #50 dated 01/17/22 revealed the resident had a communication problem related to non traumatic brain injury, and sometimes understands and sometimes understood. Interventions included allow adequate time to respond, repeat as necessary, face the resident when speaking, ask yes or no questions. Review of the physician's orders for Resident #50 revealed an order dated 12/30/21 for tuberculin purified protein fraction (PPD), inject 0.1 milliliter intradermally one time a day for rule out of tuberculosis with a discontinued date of 03/09/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 30 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Medication Administration Record (MAR) for Resident #50 for January 2022 revealed the resident received the tuberculin PPD on 01/02/22, 01/04/22, 01/05/22, 01/08/22, 01/10/22, 01/13/22, 01/14/22, 01/15/22, 01/17/22, 01/18/22, 01/19/22, 01/20/22, 01/21/22, 01/23/22, 01/24/22, 01/25/22, 01/26/22, 01/27/22, 01/28/22, 01/29/22, 01/30/22, and 01/31/22. Review of the Medication Administration Record (MAR) for Resident #50 for February 2022 revealed the resident received the tuberculin PPD on 02/01/22, 02/4/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22, 02/10/22, 02/17/22, 02/18/22, 02/20/22 02/22/22, 02/25/22, and 02/27/22. Review of the Medication Administration Record (MAR) for Resident #50 for March 2022 revealed the resident received the tuberculin PPD on 03/01/22 and 03/03/22. Observation on 02/28/22 at 12:10 P.M. of Resident #50 revealed Resident #50 was resing in bed with eyes closed and appeared to be sleeping. Resident #50 was clean and without odor. Resident #50 was dressed in appropriate clothing for the season. Interview on 03/31/22 at 11:25 A.M. with Licensed Practical Nurse (LPN) #637 revealed she was unable to count how many times Resident #50 received the tuberculin injections. LPN #637 further stated she gave it multiple times before she realized there was an error and it was discontinued. LPN #637 stated other nurses were unable to see what had been given the day before and it just continued for months. Interview on 03/31/22 at 8:55 A.M. with RDCS #636 verified the MAR for Resident #50 was signed with multiple injections related to the TB exposure protocol. RDCS #636 further stated a medication error was initiated at that time. Review of online medscape reference revealed before administration of Aplisol, located at https://reference.medscape.com/drug/aplisol-tubersol-tuberculin-purified-protein-derivative-343175#5, revealed to review the patient's history with respect to possible immediate-type hypersensitivity to the product, determination of previous use of the agent, and the presence of any contraindication to the test. Review of the facility policy titled Medication Administration, dated 12/14/17, revealed medication was to be administered as prescribed by the provider. Further review of the policy revealed medications that are withheld or not given will be documented. This deficiency represents ongoing noncompliance from the survey dated 03/02/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 31 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 - Some 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** 4. Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to open wound right and left lower leg, obesity, necrotizing fasciitis, depression, non pressure chronic ulcer lower leg, obstructive sleep apnea, mental disorder, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed an intact cognition. Review of the plan of care for Resident #21 dated [DATE] revealed Resident #21 had impaired skin integrity, or was at risk for altered skin integrity due to open wound to right and left lower leg related to necrotizing fascitits. Interventions included administer medications as ordered, monitor for side effects and effectiveness, administer treatments as ordered by medical provider, apply barrier creams post incontinent episodes, assist with repositioning, assist with toileting, bilateral assist bars, and educate resident on need for turning and repositioning. Review of the physician orders for Resident #21 revealed an order dated [DATE] to cleanse Left and right leg posterior wound with Dakins, pat dry, apply silver alginate, cover with abdominal dressing, and secure with kling wrap, wrap with ace wrap from toes to knees. Change daily and as needed. Observation on [DATE] at 10:11 A.M. in Resident #21's room revealed a bottle of opened unsecured Dakins solution on the shelf above the refrigerator. The label on the Dakins solution stated to keep out of reach of children and notifiy poison control if injested. Interview on [DATE] at 10:30 A.M. with Registered Nurse (RN) #901 verified the bottle of Dakins solution was in Resident #21's room and should not have been. RN #901 further stated the solution should be in the treatment cart. 5. Medical record review for Resident #10 revealed an admission on [DATE] with diagnoses that include but not limited to post traumatic osteoarthritis, hypertension, and overactive bladder. Review of the comprehensive MDS assessment for Resident #10 revealed an intact cognition. Review of the plan of care for Resident #10 revealed it was silent for self administration of medication . Review of the medication administration record for Resident #10 revealed orders for clopidogrel Bisulfate tablet 75 milligrams (mg) one tablet one time a day for blood clot prevention, Losartan potassium 25 mg one tablet by mouth every day for hypertension, and oxybutynin chloride extended release five mg tablet one time a day for bladder spasms. Observation on [DATE] at 10:20 A.M. revealed Resident #10 and Resident #10's room revealed a clear medication administration cup with three pills in it sitting on a shelf on top of a prescription bottle. One pill was green, one was beige, and one was white. Further observation revealed a bottle of prescription medications labeled vesicare, a second bottle of medications labeled plavix, and a topical nail solution was noted on a shelf beside the bed. Additionally, all prescription bottles had visible medication in them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 32 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 - Some Interview on [DATE] at 10:35 A.M. with Licensed Practical Nurse (LPN) #622 revealed Resident #10 should not have any medications in her room unsecured. LPN #622 removed all observations medication from Resident #10's room. Review of the facility policy titled Medicaion Storage, dated 09/2018, revealed potentially harmful substances should be clearly identified and stored in a locked area. Additionally medicaion should be stored in a secured area. Based on medical record review, observation, and staff interview, the facility failed to ensure the safe storage of drugs and biologicals. This affected three residents (#5, #7, and #51) of twenty-two residents (#40, #27, #7, #11, #67, #73, #41, #38, #69, #77, #51, #37, #31, #34, #45, #47, #39, #72, #49, #5, #80, and #182) who receive medications from the first-floor medication cart. Additionally, this affected two residents (#10 and #21) out of 18 residents reviewed for medications left at bedside. The faciity census was 75. Findings include: 1. Review of Resident #5's medical record revealed an admission date of [DATE]. admission diagnoses included chronic obstructive pulmonary disease (COPD), anemia, and cerebral infarction. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #5's plan of care dated [DATE] revealed the resident had a self-care deficit related to encephalopathy. Interventions included to administer medications and observe for side effects and effectiveness. Review of Resident #5's Medication Administration Record (MAR) revealed the resident's 9:00 A.M. medications included the following: aspirin enteric coated 81 milligram (mg.), Colace (stool softener) 100 mg., folic acid (vitamin supplement) one mg., multi-vitamin, pantoprazole (proton pump inhibitor) 40 mg., Plavix (antiplatelet) 75 mg., thiamine (vitamin supplement) 100 mg., doxycycline (antibiotic)100 mg., guaifenesin (used to relieve chest congestion) extended release (ER) 600 mg., and Detrol (used to treat overactive bladder) two mg. 2. Review of Resident #7's medical record revealed an admission date of [DATE]. admission diagnoses included congestive heart failure, chronic obstructive pulmonary disease, acute kidney failure, and necrosis of unspecified bone. Review of Resident #7's MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #7's plan of care dated [DATE] revealed Resident #7 had a self-care deficit and required the nurse to administer her medications. Review of Resident #7's Medication Administration Record (MAR) revealed the resident's 9:00 A.M. medications included the following: Atorvastatin (used to treat high cholesterol and triglycerides) 20 milligram (mg.), Calcitriol (vitamin supplement) 0.25 micrograms (mcg.), Calcium-Vitamin D 500-125 mg., Cholecalciferol (vitamin supplement) 25mg., Cyanocobalamin (vitamin supplement) 500 mcg., escitalopram (used to treat depression and anxiety) 10 mg., Folic acid 400 mcg., Gabapentin (anticonvulsant) 100 mg., Prednisone (steriod) five mg., Protonix (proton pump inhibitor) 40 mg., carvedilol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 33 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 - Some (beta blocker) 25 mg., Procardia (used to treat high blood pressure and chest pain) XL 30 mg., hydralazine (used to treat high blood pressure) 25 mg., and Tylenol 1000 mg. Observation and interview on [DATE] at 10:22 A.M. with the Director of Nursing (DON) of the first-floor medication cart revealed there were two unlabeled medicine cups with multiple pills in each cup observed in the top drawer of the medication cart. The DON confirmed the unlabeled medications are not to be stored in the medication cart. The DON confirmed two unlabeled medication cups were observed in the top drawer of the medication cart. Interview on [DATE] at 10:30 A.M. with Registered Nurse (RN) #699 confirmed the two unlabeled medication cups belonged to Resident #5 and #7. RN #699 revealed Resident #5 wanted the medications left at bedside and was told that she could not comply with the resident's request. RN #699 revealed Resident #7 requested to receive their medication after breakfast. RN #699 stated she had not been back to administer either resident's medication. RN #699 confirmed the medications in the med cups were the resident's 9:00 A.M. medications. RN #699 confirmed the medications cups were unlabeled. 3. Review of Resident #51's medical record revealed an admission date of [DATE]. admission diagnoses included diabetes with foot ulcer, end-stage renal disease, and atherosclerotic heart disease. Review of Resident #51's MDS dated [DATE] revealed the resident had severe cognitive deficit. Review of Resident #51' plan of care dated [DATE] revealed the resident had diabetes. Interventions included to administer medication per the physician orders. Review of Resident #51's physician orders dated [DATE] revealed Lantus Glargine 100 units/milliliter (ml.), inject 15 units subcutaneously at bedtime for diabetes. Observation and interview on [DATE] at 10:22 A.M. with the Director of Nursing (DON) of the first-floor medication cart revealed Resident #51's multi-vial of Lantus Glargine 100 units/ml. vial with an opened date of [DATE]. The DON confirmed the insulin was expired and should have been removed from the medication cart and discarded twenty-eight days after opening. The DON confirmed the improper storage of expired insulin in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 34 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident #10 revealed an admission on [DATE] with diagnoses that included but were not limited to post traumatic osteoarthritis, hypertension, and overactive bladder. Residents Affected - Some Review of the comprehensive Minimum Data Set for Resident #10 dated 01/03/22 revealed Resident #10 had an intact cognition. Resident #10 was coded as no mouth pain, broken or ill fitting dentures. Review of the plan of care for Resident #10 dated 01/09/22 revealed it was silent for dental services. Review of the progress notes for Resident #10 from 12/25/21 through 03/30/21 revealed they were silent for any dental services. Review of the physician's orders for Resident #10 revealed an order dated 12/25/21 for consults: podiatry, dental, optometry or ophthalmology. Observation on 03/28/22 at 9:54 A.M. of Resident #10 revealed Resident #10 was alert, well groomed, and had plaque buildup visible on teeth. Interview on 03/30/22 at 4:03 P.M. with SW #633 verified the facility does not have dental services for all residents established. SW #633 stated they are currently in the process of having a company evaluate all of the residents for dental care. SW #633 verified Resident #10 did not have a consent for dental services at that time. 5. Medical record review for Resident #21 revealed an admission on [DATE] with diagnoses including but not limited to open wound right and left lower leg, obesity, necrotizing fasciitis, depression, non pressure chronic ulcer lower leg, obstructive sleep apnea, mental disorder, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] for Resident #21 revealed Resident #21 had an intact cognition. Resident #21 was assessed for mouth or facial pain or discomfort without issues. Resident #21 was coded as no mouth pain, broken or ill fitting dentures. Review of the plan of care dated 11/19/21 for Resident #21 revealed Resident #21 had a self care performance deficit related to need for assistance with personnel care. Interventions included Resident #21 required extensive assist with personal hygiene. Review of the physician's orders for Resident #21 revealed an order dated 11/03/21 for consults: podiatry, dental, optometry or ophthalmology. Observation on 03/28/22 at 10:11 A.M. of Resident #21's teeth revealed plaque build up on both the upper and lower natural teeth. Interview on 03/29/22 at 11:40 A.M. with Resident #21 revealed she is due for her routine dental cleaning and would like to have it completed soon. Interview on 03/29/22 at 3:00 P.M. with Registered Nurse (RN) #901 revealed the social worker is the staff member that assists with dental appointments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 35 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/30/22 at 11:40 A.M. with SW #633 revealed he was unaware of the need for Resident #21 to have her teeth cleaned. SW #633 stated they have a new company being established and all residents that are eligible for dental will be placed on the list for evaluations. SW #633 verified there is not a consent for treatment for Resident #21. 6. Medical record review for Resident #50 revealed an admission on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, adult failure to thrive, respiratory failure, type two diabetes, chronic kidney disease, and dysphagia. Review of the quarterly MDS assessment dated [DATE] for Resident #50 revealed Resident #50 had impaired cognition. No behaviors were coded during the assessment period. Review of the plan of care for Resident #50 dated 01/17/22 revealed it was silent for dental care. Review of the physician's orders for Resident #50 revealed an order dated 12/15/21 for consults: podiatry, dental, optometry or ophthalmology. Observation on 03/29/22 at 9:56 A.M. of Resident #50's teeth revealed plaque build up was noted on both the upper and lower natural teeth. Interview on 03/30/22 at 11:40 A.M. with SW #633 revealed he was unaware of the need for Resident #50 to have her teeth cleaned. SW #633 stated they have a new company being established and all residents that are eligible for dental will be placed on the list for evaluations. SW #633 verified there was not a consent for treatment for Resident #50. Interview on 03/30/22 at 2:10 P.M. with State Tested Nurse Aide (STNA) #613 revealed Resident #50 was dependent on staff for dental care and stated she has not be able to clean his mouth completely. Resident #50 would [NAME] his mouth shut at times. Based on medical record review, observation, resident interview, staff interview, and review of facility contracts, the facility failed to arrange for dental services for six (#10, #21, #38, #40, #50, and #51) of seven residents reviewed for dental care. The census was 75. Findings include: 1. Review of the medical record for Resident #38 revealed an original admission date of 09/10/20 with a diagnosis of spina bifida. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 02/16/22 revealed Resident #38 was cognitively intact. Review of the March 2022 monthly physician orders for Resident #38 revealed an order dated 02/04/22 for Resident #38 to have a dental consult. Observation on 03/28/22 at 10:43 A.M. of Resident #38 revealed Resident #38 had natural teeth. Interview on 03/28/22 at 10:43 A.M. with Resident #38 confirmed she had not seen a dentist since she was admitted to the facility, that no one had offered her a dental visit, and that she would like to have regular dental visits in order to preserve her natural teeth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 36 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0791 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a diagnosis of diabetes mellitus (DM). Review of the MDS assessment for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Residents Affected - Some Review of the March 2022 monthly physician orders for Resident #40 revealed an order dated 01/05/22 for Resident #40 to have a dental consult. Review of care plan for Resident #40 dated 01/26/22 revealed Resident #40 had oral/dental problems related to history of poor oral hygiene, obvious broken or cavity teeth. Interventions included the following: dental consult as needed, observe for signs or symptoms of infection: abscess, swelling, fever, pain, redness, observe for signs and symptoms of oral/dental problems: pain, debris, cracked lips or bleeding, missing teeth, loose broken decayed teeth, observe for weight loss secondary to dental issues. Review of the nurse progress note for Resident #40 dated 02/22/22 and quarterly MDS note dated 03/17/22 revealed Resident #40 had obviously broken teeth or teeth with cavities. Observation on 03/28/22 at 9:52 A.M. of Resident #40 revealed Resident #40 had natural teeth. Interview on 03/28/22 at 9:52 A.M. with Resident #40 confirmed she had not seen a dentist since she was admitted to the facility, that no one had offered her a dental visit, and that she would like to see the dentist soon because she was experiencing a mild occasional toothache and she wanted to catch it before it turned into something bad. 3. Review of the medical record for Resident #51 revealed an admission date of 11/26/21 with diagnoses including end stage renal disease (ESRD) and DM. Review of the MDS assessment for Resident #51 dated 02/16/22 revealed Resident #51 was cognitively impaired. Review of the March 2022 monthly physician orders for Resident #51 dated 02/02/22 revealed an order for Resident #51 to have a dental consult. Observation on 03/28/22 at 2:42 P.M. of Resident #51 revealed the resident had natural teeth with some missing teeth. Interview on 03/28/22 at 2:42 P.M. with Resident #51 confirmed he had some missing teeth for which he had partial dentures, but they didn't fit anymore so he couldn't wear them. Resident #51 confirmed he had not seen a dentist since his admission to the facility, no one had offered him a dental appointment and he wanted to see if his partial dentures could be adjusted. Interview on 03/30/22 at 3:38 P.M. with Social Worker (SW) #633 confirmed Residents #38, #40, and #51, did not have consents for a dental consult, the facility had a contract with a mobile provider for dental services, but they had not arranged for the residents to be seen. Review of the contract between the mobile care provider and the facility dated and signed 07/01/21, revealed the provider offered dental services and other on-site ancillary services to improve the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 37 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0791 Level of Harm - Minimal harm or potential for actual harm quality of care and the quality of living for the residents of the facility. Further review of the contract revealed the facility would be responsible for providing information on residents requiring services and would obtain physician orders for needed services. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 38 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 observation, staff interview, and policy review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent the spread of foodborne illness. This had the potential to affect 74 out of 75 residents. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75. Findings include: 1. Observation on 03/28/22 at 9:52 A.M. of the walk-in refrigerator revealed a tray containing seven small plastic containers with covers. The containers contained yellow jello with marshmallows and had 3/12 on the lid. Culinary Director (CD) #631 was present at the time of the observation and verified the cups were dated 3/12 and stated the cups were prepared on 03/12/22 and should have been thrown out after five days (03/17/22). 2. Observation on 03/28/22 at 11:48 A.M. revealed [NAME] #624 was wearing gloves, entered the walk-in refrigerator and exited with a tomato, onion, and lettuce. [NAME] #624 took a knife and sliced the tomato and onion, and tore the lettuce, then stacked the lettuce, tomato, and onion with his gloved hand, and carried the vegetables back to the trayline. [NAME] #624 then reached into a bag of buns, retrieved a bun with his gloved hand, placed the bun on a plate, reached into the container of hamburger patties, and picked up a hamburger patty with his gloved hand, placed it on the bun, unwrapped a slice of cheese with his gloved hand, and placed the cheese on top of the hamburger patty. Interview on 03/28/22 at 11:52 A.M., with [NAME] #624 verified he did not change his gloves after exiting the walk-in refrigerator and handled the foods with the same gloved hand. 3. Observations on 03/28/22 between 11:53 A.M. and 11:56 A.M. revealed [NAME] #624 preparing plates on the tray line. [NAME] #624 scooped mechanically altered fish onto a plate. [NAME] #624 then began a new plate, utilized a gloved hand to place fish and cornbread onto the plates. [NAME] #624 was observed to rest his left gloved hand on the edge of the electric plate warmer after preparing approximately three plates, then continued to prepare additional plates, scooping pureed foods onto plates, and placing fish and cornbread onto plates utilizing the same gloved hand. Observation on 03/28/22 at 12:19 P.M. revealed [NAME] #624 reach toward his face and adjust his glasses with a gloved hand. [NAME] #624 proceeded to prepare two additional plates by placing fish and cornbread onto the plates with the same gloved hand. Interview on 03/28/22 at 12:36 P.M., with [NAME] #624 confirmed he did not use any tongs throughout the meal service and touched potentially contaminated surfaces with a gloved hand and then touched the food with the same gloved hand. [NAME] #624 stated he does not typically use tongs because he wears gloves. 4. Observation on 03/28/22 at 11:59 A.M. revealed [NAME] #624 applied new gloves, took two slices of bread and a slice of cheese over to the grill. [NAME] #624 turned a knob on the grill with his gloved hand, and then took the bread and cheese with his gloved hand and placed them into a pan to make a grilled cheese. Interview on 03/28/22 at 12:01 P.M., with [NAME] #624 verified he handled the food items after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 39 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 touching a potentially contaminated surface (knob) without changing his gloves. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled, Food: Preparation, dated 09/2017, revealed all staff will practice proper hand washing techniques and glove use and all staff will use serving utensils appropriately to prevent cross contamination. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 40 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to ensure trash cans in the food preparation area were covered. This had the potential to affect all 74 residents who receive meals from the kitchen. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75. Residents Affected - Many Findings include: Observation on 03/28/22 at 8:18 A.M. revealed an uncovered trash can on wheels next to the counter, which contained the meat slicer. Observation on 03/28/22 at 11:45 A.M. revealed an uncovered trash can on wheels sitting directly next to a counter containing a tray of small cups of portioned cake. Interview on 03/28/22 at 11:47 A.M., with Culinary Director (CD) #631 verified there were no covers on the trash cans in the food preparation area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 41 of 42 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 365562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madeira Healthcare Center 6940 Stiegler Lane Cincinnati, OH 45243 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings Include: Residents Affected - Few Medical record review for Resident #50 revealed an admission on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, neuromuscular dysfunction of bladder, type two diabetes, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed Resident #50 had impaired cognition. No behaviors were coded during the assessment period. Resident #50 had an indwelling urinary catheter. Review of the plan of care for Resident #50 dated 01/17/22 revealed Resident #50 had an indwelling catheter due to neurogenic bladder. Interventions included change catheter per orders, observe for pain and discomfort related to catheter, provide catheter care every shift, notify physician if no urinary output of if urine has an abnormal color consistency or odor, and the resident had a 16 french 10 cubic centimeter indwelling catheter. Position the catheter bag and tubing below the level of the bladder and provide privacy bag and secure catheter to the leg with security device. Review of the physician orders for the month of March 2022 for Resident #50 revealed an order dated 12/15/21 to change foley catheter 16 french/10 milliliter balloon and bag every month and as needed every night shift. Observation on 03/28/22 at 12:10 P.M. of Resident #50 laying in bed with the catheter bag hanging on the bed frame. The bottom of the catheter bag was resting on the floor. Interview on 03/28/22 at 12:19 P.M. with Regional Director of Clinical Services (RDCS) #656 verified Resident #50's catheter bag was resting on the floor and it should not have been. This deficiency represents ongoing noncompliance from the survey dated 03/02/22. Based on observation, staff interview, and medical record review the facility failed to ensure urinary catheter drainage bags were not stored directly on the floor. This affected one (Resident #50) of seven facility identified residents with urinary catheters. The census was 75. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365562 If continuation sheet Page 42 of 42