Inspection·September 23, 2021

F 0677 last been washed. Level of Harm - Minimal harm or potential for actual harm Interview on 09/20/21 at 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #9's hair appeared unwashed and the last record the facility had of resident's hair being washed was on 09/09/21. The facility did not have a policy regarding bathing but followed standards of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 2 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 record review, observation and resident and staff interview the facility failed to ensure residents wore braces as ordered by the physician to treat limited range of motion. This affected one (#24) of two facility-identified residents with orders for braces to the lower extremities. The census was 91. Findings include: Review of the medical record for Resident #24 revealed an admission date of 07/30/20 with a diagnosis of unspecified dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 07/14/21 revealed resident was cognitively impaired, required extensive assistance of one to two staff with activities of daily living (ADL's) and had limited range of motion to his lower extremities. Review of the care plan for Resident #24 dated 02/09/21 revealed resident had impaired ADL ability/mobility and required assistance of one to two staff assist in most all areas of care, was non ambulatory using a wheelchair for mobility and had right lower extremity (RLE) foot drop and used an ankle foot orthosis (AFO). Interventions included to provide treatment per the physician orders. Review of September 2021 monthly physician orders for Resident #24 revealed an order dated 06/17/21 for ankle foot orthosis (brace) to be worn to resident's right lower extremity when out of bed. Review of September 2021 Treatment Administration Record (TAR) for Resident #24 revealed the physician's order for the AFO to RLE to be when worn when out of bed was initialed off as completed. Review of the physical therapy evaluation for Resident #24 dated 04/06/21 revealed resident had peripheral neuropathy with foot drop to the right foot and wore an AFO to the RLE. Observations on 09/20/21 at 12:43 P.M. and on 09/22/21 at 1:55 P.M. revealed Resident #24 was up in his wheelchair and was not wearing the AFO to his RLE. Interview on 09/20/21 at 12:43 P.M. with Resident #24 confirmed he used to wear a brace to his right foot a few months ago but hadn't worn it recently. Interview on 09/22/21 at 1:55 P.M. with Resident #24 confirmed he was not wearing a brace to his right foot and he wasn't sure where the brace was. Observation on 09/20/21 at 2:00 P.M. with the Director of Nursing (DON) revealed the AFO for Resident #24 was being stored inside resident's closet. Interview on 09/20/21 at 2:00 P.M. with the DON confirmed Resident #24 was not wearing the AFO to his RLE, the AFO was being stored inside the resident's closet, and the resident had a physician's order to wear the AFO when he was out of bed. Interview on 09/22/21 at 2:57 P.M. with the Administrator confirmed the facility did not have a policy regarding braces and splints but the facility staff should follow the physician's orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 3 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 regarding brace application. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 4 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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** Based on record review, staff interview, review of facility incident investigation, and review of facility policy, the facility failed to ensure staff followed appropriate transfer recommendations per the resident's plan of care to prevent falls and/or accidents. This affected one (#348) of nine residents reviewed for accidents. The census was 91. Findings include: Review of the medical record for Resident #348 revealed an admission date of 10/12/19 with a diagnosis of congestive heart failure and a discharge date of 06/29/20. Review of the Minimum Data Set (MDS) assessment for Resident #348 dated 06/05/20 revealed resident was cognitively intact and required extensive assistance of two staff with transfers. Review of the fall risk assessment dated [DATE] revealed resident was at moderate risk for falls. Review of the care plan for Resident #348 dated 02/06/20 revealed resident had a history of falls, declines in activities of daily living (ADL) ability/mobility, non-ambulatory with wheelchair used for mobility, Hoyer lift transfers per staff, dependent on staff for assistance with all care. Interventions included two person physical assistance with transfers using the Hoyer lift and intervention dated 04/06/20 to educate staff to follow the [NAME] and transfer resident with the assistance of two staff to prevent injury. Review of the nurse progress note for Resident #348 dated 04/04/20 revealed resident had a witnessed fall in which his knees gave out during transfer from wheelchair to bed. Further review of note revealed the resident required the assistance of two staff with transfers, but the state tested nursing assistant (STNA) transferred the resident per self and used only one staff for the transfer. Review of the facility fall investigation dated 04/06/20 revealed Resident #348 had a fall during a one-person transfer, staff was not using a gait belt during the transfer, and the facility's follow up intervention was to educate staff to follow safety measures included in the resident's care plan. Review of the nurse progress note for Resident #348 dated 04/15/20 revealed resident sustained a skin tear to his right outer forearm during a one person transfer per STNA. The skin tear was 3.0 centimeters (cm) by 3.0 cm, was L-shaped, and had a small amount of bleeding. The nurse approximated the edges of the skin tear with a sterile Q-tip, cleansed the wound with normal saline and applied Steri strips. Further review of the note revealed the STNA transferred the resident per self and told the nurse she was not aware the resident was a two person assist using a gait belt. Review of facility incident investigation dated 04/15/20 revealed Resident #348 was interviewed after the incident and reported the STNA put him in bed by herself and almost dropped him and hit his arm on the side of the bed causing a skin tear. Further review of the investigation revealed a gait belt was not used during the transfer and the facility's follow up intervention was education to the STNA that resident transfers with two staff and a gait belt should be used. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 5 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 Review of the facility policy titled Fall Management dated 01/2021 revealed each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls and each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. The interventions will be monitored for effectiveness and the plan of care will be revised as needed. Residents Affected - Few Interview on 09/22/21 at 2:36 P.M. with the Administrator confirmed Resident #348's care plan was not followed regarding use of two staff with transfer and use of a gait belt on 04/04/20 when resident had a witnessed fall and on 04/15/20 when resident sustained a skin tear. This deficiency substantiates Complaint Number OH00111290 and Complaint Number OH00113767. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 6 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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** Based on record review, observation, staff and resident interview, review of manufacturer recommendations and review of facility policy, the facility failed to label resident oxygen tubing and with the date it was initiated. The facility also failed to ensure staff did not use expired distilled water in resident's mechanical ventilation device. This affected one (#9) of nine facility-identified residents receiving respiratory treatments. The census was 91. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS). Review of Minimum Data Set (MDS) assessment for Resident #9 dated [DATE] revealed resident was cognitively intact and required extensive assistance of two staff with activities of daily living (ADL's). Review of [DATE] physician orders for Resident #9 revealed the following respiratory treatment orders: humified oxygen at two liters per minute per nasal cannula, change and date all oxygen tubing on Monday, check water level in ventilator daily and fill with distilled water to maintain recommended level every night shift. Review of the care plan for Resident #9 dated [DATE] revealed resident was at risk for altered respiratory status and had difficulty breathing related to pleural effusion, history of acute respiratory failure with hypercapnia, history of pneumonia, and received oxygen therapy. Interventions included the following: give medications as ordered by physician, monitor/document side effects and effectiveness, monitor for signs and symptoms of respiratory distress and report to physician as needed, oxygen settings: oxygen via nasal prongs/mask at two liters per minute continuously, humidified, non-invasive mechanical ventilator to be worn at bedtime and planned daytime naps at pre-set settings as tolerated for a minimum of four hours per day, document hours of compliance. Observation of Resident #9 on [DATE] at 12:15 P.M. revealed resident had oxygen in place at two liters per nasal cannula with humidification. The oxygen tubing and the humidification bottle was undated. Further observation revealed the resident's mechanical ventilator was not in use at the time of the observation and the humidification reservoir was filled with distilled water. There was an open bottle of distilled water at the resident's bedside with a use-by date of [DATE]. The bottle was not dated upon opening. Interview on [DATE] at 12:15 P.M. with Resident #9 confirmed she wore humidified oxygen continuously at two liters. Resident #9 confirmed she was unsure when the tubing and humidification bottle had last been changed. Resident #9 further confirmed she wore the mechanical ventilator at night and the nurses filled the humidification reservoir as needed with the gallon bottle of distilled water at her bedside. Interview on [DATE] at 12:20 P.M. with Licensed Practical Nurse (LPN) #57 confirmed that neither the oxygen tubing nor the humidification bottle for Resident #9 were dated and could not determine when they had been initiated for resident. LPN #57 further confirmed the staff used the bottle of distilled water at Resident #9's bedside to fill the reservoir for the mechanical ventilator which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 7 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 Level of Harm - Minimal harm or potential for actual harm resident used at night. LPN #57 confirmed the bottle of distilled water had not been dated upon opening and had a use-by date of [DATE] and should be discarded. Review of the manufacturer's recommendations undated for Resident #9's mechanical ventilator revealed staff should change water in the humidifier daily using only distilled water (tap water will damage the unit). Residents Affected - Few Review of policy titled Oxygen Administration dated [DATE] revealed oxygen concentrators would be checked weekly, and the tubing would be changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 8 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on medical record review and staff interview, the facility failed to ensure pharmacist's Medication Regimen Review (MRR) recommendations were reviewed and addressed by the attending physician. This affected one (#63) of five residents reviewed for unnecessary medications. The census was 91. Findings include: Review of the medical record for Resident #63 revealed an admission date of 09/01/20 and a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #63 dated 08/09/21 revealed resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADL's). Review of the MRR's per the consultant pharmacist for Resident #63 dated 07/28/21 revealed Resident #63 had an ongoing order for Seroquel 25 milligrams (mg) twice a day since 01/12/21 and a dose decrease should be considered to determine the minimum effective dose. The recommendation had not been addressed by the attending physician. Review of the September 2021 physician orders for Resident #63 revealed an order dated 01/12/21 for Seroquel 25 mg twice a day. Review of the September Medication Administration Record (MAR) for Resident #63 revealed resident received Seroquel 25 mg twice a day. Review of pharmacist's recommendation dated 07/28/21 revealed Resident #63 had an ongoing order for Seroquel 25 mg twice a day since 01/12/21 and a dose decrease should be considered to determine the minimum effective dose. The recommendation was not addressed as reviewed by the attending physician. Interview on 09/23/21 at 12:30 P.M. with the Administrator confirmed facility had no evidence the MRR for Resident #63 dated 07/28/21 had been reviewed by the attending physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 9 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs related to duplicate drug therapy. This affected one (#12) of six residents reviewed for unnecessary Drugs. The facility census was 91. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of prostate, secondary malignant neoplasm of bone, neoplasm related pain acute and chronic, abnormal weight loss, emphysema, anxiety disorder, and arthritis. The resident was receiving hospice services on admission. Review of an admission Minimum Data Set (MDS) assessment of the resident dated 07/08/21 revealed the resident had good cognitive skills, and required the limited assistance of one staff to complete activities of daily living. The resident reported having constant pain when assessed. Review of a facsimile communication between a hospice nurse and the resident's physician dated 08/16/21 revealed the hospice nurse, Registered Nurse (RN) #500 communicated to the physician the resident was having severe bilateral jaw pain despite frequent increases in his pain medications. The nurse noted in the communication the resident was saying that his other pain was better overall. Hospice RN #500 also notified the physician that on investigation the resident was stating he had jaw pain even before he knew he had cancer. The nurse documented in the communication that maybe the pain (jaw pain) was related to anxiety or TMJ (temoromandibular joint dysfunction). RN #500 then requested of the physician to try scheduled Ativan (an anti-anxiety medication) 1.0 milligram (mg) routinely at bed time to see if it would help, as the pain was reportedly worse at night. The resident's physician agreed to an order for 1.0 mg of Ativan at bedtime. The physician also documented at the bottom of the facsimile communication to also add Naprosyn, a non-steroidal anti-inflammatory medication (NSAID), 500 mg twice daily if the resident was not already receiving an NSAID, and signed the document. Review of the resident's electronic medical record revealed an order was entered on 08/17/21 by Licensed Practical Nurse (LPN) #110 indicating the physician ordered for the resident to receive Naprosyn 500 mg by twice daily. Review of the resident's July and August 2021 physician's orders and medication administration record (MAR) revealed the resident had an order for and was administered Diclofenac (an NSAID) 50 mg by mouth twice daily for pain which was originally ordered on 07/22/21. The Diclofenac was ordered to be increased on 08/05/21 to 75 mg twice daily. Further review of the resident's August 2021 MAR revealed the resident was administered Naprosyn 500 mg twice daily beginning at 9:00 A.M. on 08/17/21 through 08/31/21, along with the Diclofenac as ordered. Review of the resident's physician's order and September 2021 MAR revealed the resident continued to receive both Naprosyn 500 mg twice daily, and Diclofenac 75 mg twice daily through 09/13/21 at 9:00 A.M. The Naprosyn was then discontinued on 09/13/21. The resident received both the Naprosyn and the Diclofenac starting the evening 08/17/21 through the morning of 09/13/21 for a total of 45 doses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 10 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 0757 of Naprosyn that the physician ordered noted to order only if the resident was not already on an NSAID. Level of Harm - Minimal harm or potential for actual harm Review of a medication regimen review (MRR) of the resident's medication dated 08/31/21 by a Registered Pharmacist revealed a notation for the physician which documented the resident was on Naprosyn 500 mg and Diclofenac 75 mg, and questioned if both NSAID's were needed. The physician responded to the Registered Pharmacist recommendation on 09/09/21, agreed with the recommendation and ordered to discontinue the Naprosyn on 09/09/21. The Naprosyn was discontinued on 09/13/21. Residents Affected - Few During interview on 09/22/21 at 3:31 P.M. with the Director of Nursing (DON) the resident's MAR's were reviewed, and the facsimile communication document from Hospice RN #50 to the physician. The DON affirmed the resident should not have received the Naprosyn based on the physician note directing the Naprosyn not to be started/ordered if the resident was already receiving an NSAID. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 11 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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. Based on medical record review, staff interview, review of online medication resource Medscape, and review of the facility policy, the facility failed to ensure a resident was free from unnecessary psychoactive medications regarding the use of an antipsychotic medications without an adequate indication for use. This affected one (#63) of 18 residents with orders for antipsychotic medications. The census was 91. Findings include: Review of the medical record for Resident #63 revealed an admission date of 09/01/20 and a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #63 dated 08/09/21 revealed the resident was cognitively impaired, required extensive assistance of one to two staff with activities of daily living (ADL's), was coded negative for the presence of behavioral symptoms, received antipsychotic medication on seven out of seven days during the review period, a gradual dose reduction of the antipsychotic had not been attempted and the physician had not documented a GDR as clinically contraindicated. Review of the September 2021 physician orders for Resident #63 revealed an order dated 01/12/21 for the antipsychotic medication Seroquel 50 milligrams (mg) twice a day. Review of the care plan for Resident #63 dated 01/12/21 revealed resident was on Seroquel for delusional disorder/psychosis, and she exhibited behaviors such as paranoia and screaming/yelling at staff with threats of physical abuse. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness consult with pharmacy, physician to consider dosage reduction when clinically appropriate, discuss with physician, family regarding ongoing need for use of medication, educate the resident, family, caregivers about risks, benefits and the side effects and/or toxic symptoms of Seroquel, monitor/record occurrence of for target symptoms; seizures and document per facility protocol. Further review of the care plan revealed the resident had been on Seroquel since September 2020 and the medication was put on hold on 11/27/20 for a possible discontinuation but was restarted on 11/30/20 and the dose was increased on 12/09/20 and again on 01/12/21. The care plan did not include nonpharmacological interventions to treat behaviors related to dementia. Review of pharmacist's recommendation dated 07/28/21 revealed Resident #63 had an ongoing order for Seroquel 25 mg twice a day since 01/12/21 and a dose decrease should be considered to determine the minimum effective dose. Review of the attending physician progress notes dated 01/01/21 through 09/23/21 revealed the notes contained no documentation regarding use of Seroquel use for Resident #63. Review of the Medication Administration Records (MAR's) for Resident #63 dated September 2020, October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, June 2021, July 2021, August 2021, and September 2021 revealed resident received Seroquel routinely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 12 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 Interview on 09/23/21 at 12:00 P.M. with the Administrator confirmed Resident #63 had received Seroquel routinely since September 2020 and did not have an appropriate diagnosis associated with its use and resident's record did not include a clinical rationale justifying the use of the antipsychotic medication. The facility confirmed Resident #63 is elderly with a diagnosis of Alzheimer's disease. Review of the facility policy titled Psychotropic Medications dated 02/28/20 revealed all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for efficacy, risks, benefits, and harm or adverse consequences, antipsychotic medications used to treat behavioral or psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rational for use, and may not be used for a behavior with an unidentified cause, antipsychotic's used to treat BPSD must receive gradual dose reduction and behavioral interventions, unless contraindicated. Review of the online resource Medscape at https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984 revealed Seroquel included black box warnings indicating the medication placed elderly patients with dementia related psychosis at increased risk of cardiovascular and infectious related deaths and was not approved for the treatment of patients with dementia-related psychosis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 13 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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** Based on observation, staff interview and policy review, the facility failed to ensure expired control solution for blood glucose monitors and an expired insulin pen was properly removed from the medication carts. This had the potential to affect five (#17, #24, #43, #74 and #93) residents who utilized glucose monitors and one (#89) of three resident's observed to utilize insulin pens. The facility census was 91. Findings included: 1. Observation on [DATE] at 4:01 P.M. of the medication cart on two-west revealed the blood glucose control monitor solution had expired. The high control solution had an expiration date of [DATE]. The low control solution had an expiration date of [DATE]. Interview on [DATE] at 4:08 P.M. with Licensed Practical Nurse (LPN) #59 confirmed the blood glucose control solutions were expired. LPN # 59 revealed three residents (#24, #43, #74) received blood glucose monitoring on the two-west hallway. LPN #59 denied being aware any unusual blood glucose readings. 2. Observation on [DATE] at 4:22 P.M. of the medication cart on the memory care revealed the blood glucose monitor solution had expired. The high control solution had an expiration date of [DATE] and the low control solution had an expiration date of [DATE]. Interview on [DATE] with LPN #160 confirmed the control solution on the memory care medication cart was expired. The LPN #160 revealed two residents (#93 and #17) received blood glucose monitoring on the unit. LPN #160 denied being aware of any concerns related to unusual blood glucose readings. 3. Observation on [DATE] at 11:48 A.M. of the one-north medication cart revealed Resident #89's insulin Lispro injectable pen with an opened date of [DATE]. Interview with Registered Nurse (RN) #59 confirmed Resident #89's insulin pen was expired and should have been discarded twenty-eight days after opening. The RN #59 confirmed the resident had a new unopened insulin injectable pen. Review of the facility policy titled, Medication Administration, dated [DATE] revealed outdated medications are immediately removed from stock and disposed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 14 of 15 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 365693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Western Hills Retirement Village 6210 Cleves Warsaw Pike Cincinnati, OH 45233 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 medical record review, observations, staff interviews, review of the facility policy, and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore appropriate personal protective equipment (PPE) when entering resident rooms who were in Coronavirus Disease 2019 (COVID-19) quarantine to potentially prevent the spread of COVID-19. This affected one (#398) out of 91 residents observed for infection control. The facility census was 91. Residents Affected - Few Findings include: Review of Resident #398's medical record revealed an admission date of 09/14/21 from an acute care facility. Diagnoses included heart attack, irregular heartbeat, and high blood pressure. Further medical record review revealed Resident #398 was not vaccinated against COVID-19. Review of the most recent admission assessment dated [DATE] revealed Resident #398 had cognitive impairments and required extensive assist of two with all care. Review of the physician's orders dated 09/14/21 revealed the resident was to be monitored every shift for COVID-19 symptoms. Additionally, Resident #398 was ordered for be in COVID-19 quarantine isolation for fourteen days. Observations on 09/20/21 at 12:20 P.M. revealed a container outside the resident's room containing PPE. Signs were posted noting proper PPE to wear during care or visits. Staff are to wear a mask, face shield, gown, and gloves. admission Coordinator (AC) #121 was observed in Resident #398's room. Further observations revealed AC #12 was wearing a surgical mask, and face shield; however, the observations revealed the staff member was not wearing a gown or gloves. Interview with the Director of Nursing (DON) on 09/20/21 at 12:25 P.M. confirmed AC #121 was not wearing proper PPE when entering Resident #398's room. The DON called AC #121 out of the room and handed her a gown and gloves. Interview with the AC #121 on 09/20/21 at 12:30 P.M. revealed she was just not thinking and just went into the Resident #398 room without donning the proper PPE. Review of the facility COVID-19 policy dated 10/06/20 revealed proper PPE should be worn to prevent the spread of COVID-19. Review of information from the CDC titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed in general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Additionally, unvaccinated residents who have had close contact with someone with COVID-19 or SARS-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if viral testing is negative. Healthcare Personal (HCP) caring for these residents should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365693 If continuation sheet Page 15 of 15