Inspection·June 28, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on resident and staff interviews, policy review, observations, and record review, the facility failed to provide reasonable accommodation of a call light that adapted to the needs of the resident. This affected one (Resident #50) of three residents reviewed for accommodation of needs. The facility census was 72. Residents Affected - Few Findings include: Review of Resident #50's medical record revealed an admission date 07/28/2001. Diagnoses included acute respiratory failure with hypoxia, bipolar disorder, anxiety, chronic respiratory failure, emphysema, adult failure to thrive, Wilson's disease, and insomnia. Review of the Minimum Data Set (MDS) assessment, dated 04/01/23, revealed Resident #50 had intact cognition and had verbal behavioral symptoms directed towards others occurring four to six days a week. Resident #50 was dependent on staff for eating, toileting, and wheelchair mobility. Resident #50 required two-person assistance with bed mobility and transfers. Resident #50 had upper extremity impairment and lower extremity impairment on both sides of her upper and lower body. Review of the plan of care dated 07/30/21 revealed Resident #50 was at risk for developing complications related to receiving assistance with the following activities of daily living tasks: bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Interventions included was to have the call light within easy reach and encourage Resident #50 to use it for assistance as needed and to respond promptly to all requests for assistance. Interview and observation on 06/25/23 at 12:40 P.M., with Resident #50 revealed the inability to use the call light that has been provided to Resident #50. Resident #50 stated that because of the contractures in both hands and the constant shaking, Resident #50 has requested a touch pad call light in the past. Observation of Resident #50's multiple attempts to utilize the push button call light clipped to the clothing on Resident #50's chest was unsuccessful, leading Resident #50 to yell out for assistance. Resident #50 further stated she had to yell out for help because she cannot use the call light that has been provided. At 12:46 P.M., Licensed Practical Nurse (LPN) #37 entered Resident #50's room after Resident #50's multiple yells for assistance. Resident #50 requested to be repositioned in her wheelchair and to have a touch pad call light. LPN #37 verified the inability for Resident #50 to use a push button call light and that a touch pad call light would be provided. Observations and interviews with Resident #50 on 06/26/23 at 11:02 A.M. and 06/27/23 at 7:47 A.M. revealed a push button call light clipped to chest of Resident #50. Resident #50 stated she was told that staff were looking for a touch pad call light. Review of the facility policy titled Answering the Call Light, dated 2001, indicated the purpose of the procedure is to respond to the resident's requests and needs. Giving guidelines to demonstrate the use of the call light, and to ask the resident to return the demonstration so that that you will be sure that the resident can operate the system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 2 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of the facility's Self-Reported Incidents (SRIs), and policy review, the facility failed to timely report an allegation of misappropriation of a resident's credit card to administration and the State Survey Agency. This affected one (Resident #49) of one resident reviewed for abuse and misappropriation. The facility census was 72. Findings include: Record review for Resident #49 revealed the resident was admitted to the facility on [DATE]. Diagnoses included depression, muscle weakness, and altered mental status. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition and required limited assistance with mobility. Review of the facility's SRI , dated 06/26/23 at 5:54 P.M., revealed the Administrator filed an SRI report regarding Resident #49's allegation of a missing credit card. Interview on 06/26/23 at 8:38 A.M. with Resident #49 stated he was missing his credit card about two weeks prior and anyone could have taken it. Resident #49 stated he told Social Service Designee (SSD ) #79 it was missing and someone could have taken it. Resident #49 stated SSD #79 and other staff searched his room and the credit card was not found. Interview on 06/26/23 at 3:41 P.M. with SSD #79 verified Resident #49 reported a missing credit card on 06/23/23. SSD #79 stated Housekeeping Director #99 and herself searched Resident #49's room and could not locate the missing credit card. SSD #79 verified Resident #49 reported the credit card could have been taken by anyone. SSD #79 stated she did not report the allegation to the Administrator as she was unsure if Resident #49 had a credit card, no one had seen him use it, nothing else was missing, and it was late in the afternoon on a Friday when the allegation was made by Resident #49. SSD #79 stated she had been in serviced on reporting missing items and should have reported the allegation to the Administrator immediately. SSD #79 stated she did not assist Resident #49 in removing accessibility to the credit card on 06/23/23. Interview on 06/27/23 at 10:23 A.M. with the Administrator verified an SRI was filed on 06/26/23 at 5:54 P.M. for the allegation of Resident #49's missing credit card, as reported to SSD #79 on 06/23/23. The Administrator verified she had no knowledge of the missing credit card until 06/26/23 at 5:29 P.M. when the State Survey Agency reported the allegation to the Administrator. The Administrator stated Resident #49's credit card was canceled on 06/27/23 and Resident #49 was receiving a replacement credit card. The Administrator verified the allegation should have been reported on 06/23/23, when the SSD #79 became aware of the allegation and an SRI should have been submitted to the State Survey Agency immediately. Review of the facility policy titled Abuse and Neglect Protocol, dated 06/13/21, revealed all employees must immediately report any suspected abuse to the Director of Nursing or the Administrator. If the incident occurs or is discovered after hours, the Administrator must be called at home and informed. The incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. The reported information must include the name of the resident, time and date of the incident, and where the incident took place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 3 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure the residents' completed Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare and Medicaid Service's (CMS) system within 14 days after completion of the assessment. This affected four (#4, #40, #42, and #51) of 18 residents reviewed for MDS assessments. The facility census was 72. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included neurogenic bladder, multiple sclerosis and depression. Review of Resident #4's quarterly MDS assessment revealed Resident #4's quarterly MDS assessment was completed on 05/25/23 and the MDS assessment should have been submitted to the CMS system on 06/06/23. The MDS assessment was submitted to the CMS system on 06/20/23. This was greater than 14 days after the MDS assessment completion date. Interview on 06/28/23 at 1:22 P.M. with MDS Coordinator (MDSC) #1 verified Resident #4's completed MDS assessment dated [DATE] was submitted greater than 14 days after completion. MDSC #1 stated she had been using 21 days as submission protocol and was unable to submit the completed assessments within 14 days. 2. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE]. Diagnoses included anxiety disorder, schizophrenia and manic depression. Review of Resident #40's quarterly MDS assessment revealed Resident #40's quarterly MDS assessment was completed on 05/07/23 and the MDS assessment should have been submitted to the CMS system on 05/21/23. The MDS assessment was submitted to the CMS system on 06/20/23. This was greater than 14 days after the MDS assessment completion date. Interview on 06/28/23 at 1:22 P.M. with MDS Coordinator (MDSC) #1 verified Resident #40's completed MDS assessment was submitted greater than 14 days after completion. MDSC #1 stated she had been using 21 days as submission protocol and was unable to submit the completed assessments within 14 days. 3. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included coronary artery disease, hypertension, and renal insufficiency. Review of Resident #42's quarterly MDS assessment revealed Resident #42's quarterly MDS assessment was completed on 04/27/23 and the MDS assessment should have been submitted to the CMS system on 05/11/23. The MDS assessment was submitted to the CMS system on 06/26/23. This was greater than 14 days after the MDS assessment completion date. Interview on 06/28/23 at 1:22 P.M. with MDS Coordinator (MDSC) #1 verified Resident #42's completed MDS assessment dated [DATE] was submitted greater than 14 days after completion. MDSC #1 stated she had been using 21 days as submission protocol, and was unable to submit the completed assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 4 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0640 within 14 days. Level of Harm - Potential for minimal harm 4. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE]. Diagnoses included anemia, dementia, and depression. Residents Affected - Some Review of Resident #51's quarterly MDS assessment revealed Resident #51's quarterly MDS assessment was completed on 05/25/23 and the MDS assessment should have been submitted to the CMS system on 06/06/23. The MDS assessment was submitted to the CMS system on 06/20/23. This was greater than 14 days after the MDS assessment completion date. Interview on 06/28/23 at 1:22 P.M. with MDS Coordinator (MDSC) #1 verified Resident #51's completed MDS assessment dated [DATE] was submitted greater than 14 days after completion. MDSC #1 stated she had been using 21 days as submission protocol, and was unable to submit the completed assessments within 14 days. Review of the RAI manual revealed an Omnibus Budget Reconciliation Act (OBRA), completed assessments would need to be submitted no more than 14 days completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 5 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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** Based on resident and staff interview and record review, the facility failed to ensure a resident who required assistance from staff with activities of daily received bathing as scheduled. This affected one (Resident #32) of three residents reviewed for activities of daily living. The facility identified all 72 residents required assistance from staff with bathing. The facility census was 72. Residents Affected - Few Findings include: Record review revealed Resident #32 was admitted on [DATE] with pertinent diagnosis of: morbid obesity, major depressive disorder, acute kidney failure, and hypotension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact and required physical assistance from one person for bathing. Resident #32 did not reject care. Review of the electronic documentation and paper shower record sheets records on 06/28/23 revealed Resident #32 received a shower/bed bath on 5/02/23 and did not receive another one until 05/19/23. Resident #32 went 16 days without a bed bath/shower. Interview with Resident #32 on 06/25/23 at 4:27 P.M. revealed she does not get enough bed baths. It was supposed to be twice a week but said she was lucky to get one bed bath a week. Interview with the Director of Nursing (DON) on 06/28/23 at 11:46 A.M. verified Resident #32 did not receive a bed bath from 05/03/23 to 05/18/23. The DON verified Resident #32 does not refuse bed baths. This deficiency represents non-compliance investigated under Complaint Number OH00143496. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 6 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to have ensure the resident's pressure ulcers were documented accurately upon re-admission to the facility. This affected one (#28) of four residents reviewed for pressure ulcers. The facility census was 72. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed Resident #28 was readmitted to the facility on [DATE]. Diagnoses included stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) of left buttock, stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fate may be visible but bone, tendon or muscle is not exposed) of the left ankle, stage IV pressure ulcer to the sacral region, stage IV pressure ulcer to the left hip. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively impaired. Review of the hospital documentation dated 05/24/23 revealed Resident #28 had five stage IV pressure ulcers on the left hip, left buttocks, sacrum, right buttocks, and the right hip and one deep tissue injury (DTI) (purple or maroon area of discolored intact skin) on the left ankle. The hospital had six documented pressure ulcers. Review of the readmission assessment dated [DATE] revealed Resident #28 was readmitted to the facility with one pressure injury on the coccyx. Review of the nursing progress notes dated 06/13/23 at 3:24 P.M. revealed Resident #28 returned from the hospital with a wound to the coccyx. There was no measurement or description of the wound and no mention of any other areas of skin breakdown. The nursing progress note dated 06/15/23 revealed there was a pressure injury to the right neck under collar noted by the respiratory team. The area was present upon admission. Review of Resident #28's wound assessment dated [DATE] revealed Resident #28 was admitted on [DATE] with the following seven pressure ulcers: stage III pressure ulcer to her sacrum, a stage IV pressure ulcer to her right buttocks, a stage IV pressure ulcer to the IT band, a stage IV left buttocks, a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) on right posterior neck, a DTI to the left ankle, and a stage II to the right hip. Interview on 06/27/23 at 9:30 A.M. with the Director of Nursing (DON) verified Resident #28's re-admission assessment dated [DATE] and the subsequent progress note on 06/13/23 was inaccurate and incomplete. The re-admission assessment did not include the six of the seven pressure ulcers. There were no measurements and descriptions of the wounds upon re-admission on [DATE]. The DON verified the hospital documentation from 05/24/23 and the facility's wound assessment on 06/19/23 did not match the facility's re-admission assessment dated [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 7 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation, policy review, and staff interview, the facility failed to prepare puree foods as planned in the facility's spreadsheet and recipes. This had the potential to affect all nine residents (Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59) receiving pureed food from the kitchen. The facility census was 72. Findings include: Review of the facility's lunch menu spreadsheet dated 06/27/23 revealed the puree meal consisted of cheesy ham and egg scramble with a number 10 scoop size (three-eights cup), wheat toast with a number 16 scoop size (one-fourth cup), cereal, juice, and milk. Review of the facility's recipe for Cheesy Ham and Egg Scramble revealed for puree consistency required four quarts of liquid eggs, two pounds of ham and two pounds of shredded cheese to be mixed together, cooked, and then pureed with milk, to obtain a puree consistency. Observation on 06/27/23 at 7:14 A.M. revealed Dietary [NAME] (DC) #92 preparing pureed eggs, ham and cheese in a blender for the breakfast meal. There was no recipe or spreadsheet visible on the counter. DC #92 added cheese, unmeasured, to the cooked eggs and ham into the blender. DC #92 added slices of bread into the egg mixture. DC #92 completed the puree process. During meal service, DC #92 used a number eight scoop size (four-ninths cup) for the puree mixture to serve the puree egg mixture. Interview on 06/27/23 at 7:26 A.M. with DC #92 verified she should have followed a recipe for the amount of cheese and ham added to the mixture. DC #92 verified she did not prepare the bread puree separate from the egg puree mixture, as listed on the spreadsheet. DC #92 stated she added the bread to the egg puree mixture because it makes a better consistency. DC #92 verified the bread should have been prepared separately from the egg mixture to obtain the correct food portion and should have used a number 10 scoop size for the eggs and a number 16 scoop size for the puree bread. Interview on 06/27/23 at 10:00 A.M. with Dietary Manager (DM) #85 verified DC #92 should not have pureed the eggs and bread together per the facility's recipe and the spreadsheet. DM #85 verified DC #92 utilized the wrong scoop size for the egg and bread mixture and did not follow the spreadsheet. DM #85 verified DC #92 had access to the recipe and spreadsheet to accurately prepare the puree foods. Review of the resident's physician orders revealed Residents #1, #7, #9, #20, #23, #26, #27, #56, and #59 had diet orders for puree food consistency. Review of the facility policy titled Menu Planning, dated May 2021, revealed diets must be planned in accordance with the diet manual and meet nutritional needs of resident. Diets are modified as medically necessary following the same plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 8 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on policy review, observations, and staff interview, the facility failed to store foods, discard expired foods and maintain food equipment in good repair. This had the potential to affect 63 residents who received food from the kitchen. The facility census was 72. Findings include: 1. Observations on 06/25/23 at 9:05 A.M. with Dietary [NAME] (DC) #93 revealed the following concerns: there was an uncovered ceiling light fixture above the three-compartment sink; The deep fryer had food and debris built up along the edges and the deep fryer was not covered when not in use; The reach in freezer, located in the main kitchen area, had the exterior finish removed in areas measuring one-fourth of an inch up to a half-inch over 90 percent of each exterior door. The exposed areas were rust colored and noted to have areas which were non cleanable and unable to be sufficiently sanitized; The reach in refrigerator, in the main kitchen area had a container labeled sour cream, with an open date of 05/22/23; and the milk refrigerator outside temperature read 48 degrees Fahrenheit and there was no inside thermometer. There were no temperature logs for any refrigerator and freezer. DC #93 verified the light cover was missing on the ceiling light, and the sour cream was expired. DC #93 verified the reach in freezer had the exterior surface removed and was rusty and non-cleanable surface. Interview on 06/26/23 at 7:44 A.M. with Maintenance Director #500 stated the reach in freezer was approximately five years old and the exterior finish had been removed, with a chemical spray. He verified that nearly 90% of the door surface was covered with spots where the finished been removed. He verified the areas were rusted, indicating a non-cleanable surface. Interview on 06/27/23 at 10:00 A.M. with Dietary Manager (DM) #85 verified the foods must be labeled, dated and perishable foods discarded after three days. DM #85 verified the light above the three-compartment sink should have been covered. 2. Observation on 06/27/23 at 7:14 A.M. revealed DC #93 preparing pureed eggs in a blender. DC #93 put on gloves, added eggs into the blender bowl, touched the blender, the spatula, the bread bag, and then using the same gloves, reached into the bread bag and tore bread slices into small pieces into the pureed eggs. DC #93 did not change gloves prior to touching and adding bread to the puree eggs. DC #93 continued with the same gloves, touching the counter, utensils, and the cheese bag. DC #93 reached into the cheese bag and using the same gloved hand, pulled cheese from the bag and added the cheese to the puree eggs. DC #93 did not change gloves until the completion of the egg pureeing process. Interview on 06/27/23 at 7:26 A.M. with DC #93 verified she used the same gloved hands to touch utensils, equipment and packages using the same gloved hands without changing gloves or using utensils to touch food. DC #93 verified foods were to be handled with utensils or clean gloves when preparing foods. Interview on 06/27/23 at 10:00 A.M. with DM #85 verified DC #92 should have used utensils to handle the bread and cheese when mixing into the puree eggs or changed gloves prior to touching foods. 3. Observation on 06/28/23 at 7:53 A.M. with Medical Records Aide (MRA) #2 revealed the following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 9 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 sanitation concerns in the Unit C and Unit D resident designated refrigerators: Level of Harm - Minimal harm or potential for actual harm • Residents Affected - Some In the Unit C the resident refrigerator, the built in thermometer read at 50 degrees Fahrenheit. There was no free-standing thermometer. There was no thermometer in the freezer. There were two opened cheese packages with no open date. The cheese appeared hardened and discolored. The was a container which appeared to be meat which had a blue circle of fuzzy debris. There were two open labeled snack packages which were undated. The C unit refrigerator had brownish debris on the bottom rack. • In the Unit D resident refrigerator, the refrigerator mounted thermometer registered at 48-degree Fahrenheit. There was no free-standing thermometer inside the refrigerator. The freezer had a half-inch frozen layer of cloudy, sticky substance on the floor of the freezer. Interview on 06/28/23 at 8:06 A.M. with MRA #2 verified the Unit C and D resident refrigerators should have free standing thermometers to ensure the mounted refrigerator thermometers were accurate. MRA #2 verified the resident foods must be labeled, dated, and discarded when the date was past three days. MRA #2 verified the freezer needed cleaned. Review of the policy provided by the facility titled Ohio Department of Health Food Code, dated 2019, revealed contamination of foods can be prevented through use of gloves or utensils. Single use gloves shall be used for only one task and discarded when interruptions occur in the operation. Packaged foods must be marked and shall not exceed seven days. Food must be discarded when the food is not date marked. Review of the facility's undated policy titled Maintenance Service revealed the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 10 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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** Based on record review, observation, policy review, and staff interview, the facility failed to complete hand hygiene after removing gloves during a resident's wound treatment. This affected one (Resident #58) of three residents reviewed for infections. The facility census was 72. Residents Affected - Few Findings include: Record review for Resident #58 revealed an admission date of 03/09/22. Diagnoses included diffuse traumatic brain injury, carrier of bacterial diseases, severe sepsis with shock, and a pressure ulcer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was cognitively intact. Review of a physician's order dated 05/15/23 revealed to cleanse the pressure injury to left lateral foot between the fourth and fifth toes with soap and water or wound wash. Pat dry. Apply alginate and cover with dry dressing (either roll ABD and roll gauze or gauze and tape) every day shift for pressure injury and as needed for if dressing becomes dislodged or soiled. Observation of Licensed Practical Nurse (LPN) #44 on 06/27/23 at 2:45 P.M. revealed she was completing a dressing change for Resident #58. LPN #44 gathered her supplies including calcium alginate, abdominal pad, wound cleanser, tape, and gauze. LPN #44 washed her hands donned a gown and put on gloves. LPN #44 removed the dirty dressing on the left foot. She removed her gloves and did not use hand sanitizer or wash hands before putting on clean gloves. LPN #44 cleaned the wound with wound cleanser and then removed her dirty gloves and put on clean gloves. She did not wash her hands or use hand sanitizer after removing her dirty gloves. LPN #44 completed the dressing change by placing calcium alginate on the wound and covered with an abdominal pad, wrapped the wound in gauze, dated, and then taped wound dressing. Interview with LPN #44 on 06/27/23 at 2:55 P.M. verified she did not wash her hands or use hand sanitizer after removing dirty gloves and putting on clean gloves. Review of the facility's Handwashing/Hand Hygiene policy, dated 08/2019, revealed use an alcohol based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations, after handling used dressings, and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 11 of 12 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 365690 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036 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 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interviews, the facility failed to provide a full visual privacy of each resident. This affected six (Residents #7, #40, #50, #65, #68, and #226) of 56 residents residing in double occupancy rooms. The facility census was 72. Residents Affected - Some Findings include: 1. Observation on 06/25/23 at 12:42 P.M. of Resident #50 and Resident #7's room revealed there was one dividing curtain hanging from ceiling between the end of Resident #50's footboard and the head of the bed of Resident #7. The curtain was only able to cover three-fourth of Residents #7's bed. There was a track on the ceiling but was missing a curtain on Resident #50's side of room. Interview on 06/25/23 at 12:46 P.M. with Licensed Practical Nurse (LPN) #37 verified there was only one curtain in Resident #50 and #7's room as a divider between sides of the room. LPN #37 verified the current curtain was unable to fully provide privacy to either resident because of the width of the curtain was not wide enough to cover each resident's room area. 2. Observation on 06/25/23 from 3:20 P.M. through 3:45 P.M. revealed the following double occupied rooms and concerns with privacy curtains: • Resident #49 and #68 shared a room. There was partially missing privacy curtain ceiling track, permitting visibility of Resident #68 at the foot of the bed. • Resident #40 and #60 shared a room. For Resident #40, there was no ceiling curtain track and no privacy curtain, permitting visibility of the resident at the foot of the bed. • Resident #65 and #57 shared a room. For Resident #65, there was no privacy curtain, permitting visibility of the resident at the foot of the bed. • Resident #226 and #16 shared a room. There was partially missing curtain ceiling track, preventing complete closure of the privacy curtain for Resident #226. Interview on 06/26/23 at 4:24 P.M. with Housekeeping Director #99 verified double occupied resident rooms of Residents #49 and #68, Residents #40 and #60, Residents #65 and #57, and Residents #226 and #16. Housekeeping Director #99 verified the privacy curtains in these double occupied resident rooms were not fully functioning to provide complete privacy for Residents #40, #65, #68, and #226. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365690 If continuation sheet Page 12 of 12