Health inspection·September 20, 2018

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 interviews, medical record review, review of facility self-reported incidents and review facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, the facility failed to ensure their abuse policy was implemented to investigate an allegation of abuse. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Residents Affected - Few Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 2 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed it was the facility's policy to investigate all alleged violations involving abuse and staff should report all incidents/allegations of abuse immediately to the Administrator or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 3 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 resident and staff interviews, medical record review, review of facility self -reported incidents and review of facility's policy, the facility failed to ensure an allegation of abuse was reported timely to the State Agency. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 4 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed the Administrator or his/her designee would notify the state agency of all alleged violations involving abuse as soon as possible, but in no event later then 24 hours from the time the incident/allegation was made known to the staff member. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 5 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0610 Respond appropriately to all alleged violations. 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 interviews, medical record review, review of facility self-reported incidents and review of facility policy, the facility failed to investigate an allegation of abuse. This affected one (#85) of two residents reviewed for abuse. The facility census was 117. Residents Affected - Few Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of nursing progress note dated 09/15/18 at 4:14 P.M. revealed the resident complained of discomfort to her right knee, reported no trauma but stated the pain started that morning. No redness, slight swelling noted to bilateral lower extremities from knee to toes. An order was obtained for the right knee x-ray, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of physician assistant progress note dated 09/18/18 revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. She reported RNADON #124 was rude and insulting, reported accusing someone of abuse was a very serious accusation, and accused Resident #85 of discriminating against staff. She reported feeling insulted and like dirt during the questioning. The resident reported being asked if the staff intended to cause harm and Resident #85 informed RNADON #124 of the inability to read minds but their behavior was abusive, and their definitions of abuse must be different. Review of facility self-reported incidents from 09/15/18 to 09/17/18 revealed no submission of an allegation of abuse for Resident #85. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, upon arrival to work on 09/15/18, that Resident #85 had a fall. After morning report, STNA #74 asked Resident #85 what had happened and the resident reported being dropped the previous night by the STNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 6 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Resident #85's knee hit the floor. An x-ray was obtained and was negative. RNS #192 reported she could see how the actions taken by the STNAs in an attempt to prevent a fall could have been perceived as rough, and the x-ray was negative for fracture, so no other action was needed, taken, and an allegation of abuse was not reported. Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 reported the resident council president informed her the morning of 09/17/18 that Resident #85 had called on 09/16/18 and reported staff had abused her/him. The resident council president advised Resident #85 to notify staff. RNADON #124 reported immediately interviewing Resident #85 whom reported on 09/14/18, two STNAs, one tall and one short with poofy hair abused her/him. After talking with Resident #85 further, the resident reported the STNAs were rough with care and threw her/him on the floor the night of 09/14/18. Upon asking Resident #85 what exactly was meant by abusive, the resident reported the STNAs were rushed, and wouldn't permit the resident to rock back and forth like therapy instructed. RNADON #124 reported it sounded as if the STNAs were trying to be encouraging but Resident #85 initially reported it was abusive and resulted in a fall. RNADON #124 then asked Resident #85 if staff were intentionally trying to cause harm and what abusive meant to her/him. Resident #85 then reported the STNA's rushed care and questioned why everyone had been informed about the abuse allegation. By the end of the interview, Resident #85 reported if she/he wanted to cause trouble she/he would have contacted the senator and did not make any further allegations of a fall or abuse. RNADON #124 reported a fall was any unexpected decline in elevation, even if not witnessed and all falls were investigated. All allegations of abuse were to be reported to the DON and Administrator immediately. RNADON #124 acknowledged both the resident council president and Resident #85 reported an allegation of abuse but upon interviewing Resident #85, the allegation did not meet the definition of abuse, and the resident then denied any issues by the end of the interview so an allegation of abuse wasn't reported. Review of facility's policy on Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised November 2017, revealed it was the facility's policy to investigate all alleged violations involving abuse and staff should report all incidents/allegations of abuse immediately to the Administrator or designee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 7 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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** 2. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and non-Alzheimer's dementia. Review of the admission Minimum Data Set Assessment (MDS) assessment, dated 07/06/18, revealed she had a moderate cognitive impairment. A review of the resident's face sheet revealed she was her own responsible party. Review of nursing notes, dated 08/16/18 at 11:15 A.M., documented the resident went out for an appointment at the wound clinic located in the hospital. The resident was admitted to the hospital from the appointment due to infection in her left foot. There was no evidence in the medical record the resident and/or responsible party was provided written notice of the transfer to the hospital. Interview on 09/19/18 at 12:04 P.M. with the Director of Nursing (DON) stated the resident was admitted to the hospital from [DATE] to 08/24/18 from a physician's appointment related to her left foot infection. On 09/20/18 at 6:30 P.M., the DON verified the facility did not issue a bed hold notice to the resident in writing as she was a direct admit to the hospital from her physician's appointment. Review of the facility's policy titled Facility Initiated Discharge Notification Policy, dated 11/28/17 revealed the resident and/or resident representative would be notified in writing of the facility bed hold policy upon resident transfer to the hospital. Based on record review, staff interview, and review of facility policy, the facility failed to notify the resident and/or the resident representative in writing of bed hold policies upon transfer to the hospital. This affected two (Resident #24 and #101) of three residents reviewed for hospitalization. The facility census was 117. Findings include: 1. Record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 08/27/18, revealed Resident #101 was cognitively impaired. Review of nurse's progress notes for Resident #101 revealed the resident was transferred to the hospital and was admitted with a diagnosis of fracture to the right femur on 07/23/18. Further review of the record revealed there was no notification of the facility's bed hold policy upon transfer to the hospital to either the resident or the resident's representative in Resident #101's chart. During an interview on 09/20/18 at 10:35 A.M., the Director of Nursing confirmed that neither the resident nor resident's representative had been notified in writing of the facility bed hold policy upon Resident #101's transfer to the hospital on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 8 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to ensure resident's received individual and group activities to meet their needs. This affected two (#47 and #90) of three residents reviewed for activities, received individual and group activities to meet their needs. The facility census was 117. Residents Affected - Few Findings include: 1. Review of Resident #90's record, revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to embolism of right middle cerebral artery, atrial fibrillation, right heart failure, aphasia, chronic ischemic heart disease, acute respiratory failure. Review of the admission Minimum Data Set (MDS) assessment, dated 08/17/18, revealed the resident experienced short and long term memory losses and required extensive assistance of two or more staff with bed mobility, transferring, dressing, personal hygiene, and toilet use tasks. Further review of the MDS, revealed under the area of activity preferences, it was very important for the resident to keep up with the news and to have books, newspapers, and magazines to read. Review of the activity assessment, dated 08/22/18, revealed the resident liked to watch sports and used to coach baseball. When not involved in activities, the resident liked to read and watch television. Review of the activity care plan, dated 08/22/18, revealed the resident needed activities for cognitive stimulation and social interaction related to cognitive deficits and physical limitations. Interventions included the provision of one to one bedside/in-room visits and activities if unable to attend out of room events, the resident's preferred activities were watching television, sports, and keeping up with the news, staff to provide the activities calendar monthly, and review activity participation and wishes with the family/representative. During review of the Activity Logs for the months of 08/2018 and 09/2018, it was revealed the activity staff would sign off on any activity the resident participated in on each day. During review of the current events portion of the activity logs, it was revealed there were no check marks or staff initials indicating the resident was engaged in any current event activities. During observation of Resident #90 on 09/19/18 at 10:24 A.M., the resident was observed seated in a recliner in his room. He was unable to speak, but was able to communicate by a thumbs up signal for yes, and a back and forth flip with his hand or thumbs down for no. Observation and interview with Resident #90 on 09/19/18 at 11:07 A.M., revealed the resident was in his bed per his request. He was positioned on his right side with his back away from the television. When asked if he would like to read a newspaper, he gave the thumbs up sign. When asked if staff brought in newspapers or magazines for him to read, he flipped his hand back and forth, answering no. During interview with the Activity Director on 09/19/18 at 11:20 A.M., she stated the resident had one on one activities and during these one on one activities, the staff read portions of the newspaper to him to keep him current with sports and the news. The surveyor entered the resident's room with the Activity Director at that time. She looked in his drawers and on his tables for a newspaper or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 9 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any other reading material. The Activity Director verified there was no reading material. The surveyor then asked the resident if anyone had come in on this day or the prior day to read the news to him. He flipped his hand in a back and forth motion indicating no. 2. Record review revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, stroke, non-Alzheimer's dementia, seizure disorder, anxiety, chronic lung disease, and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS) assessment, dated 07/24/18, revealed it was very important to him to listen to music he liked and to do things with groups of people. Review of his 60-day MDS assessment, dated 09/11/18, revealed he had a moderate cognitive impairment and required the assistance of staff with his activities of daily living. Review of the resident's plan of care for therapeutic recreation, initiated on 07/26/18, revealed pertinent interventions included he would be informed of activities and assisted to them. Also, he would be invited to music performances, as this was his favorite activity. On 09/19/18 at 10:36 A.M., an interview with Resident #47 revealed he would like more physical activities. The resident said he enjoyed music. On 09/19/18 at 3:20 P.M., an observation of a karaoke music activity was occurring in the dining room. An interview with Activity Assistant #122 revealed she had not invited the resident to this activity. Activity Assistant #122 said she did not go down the resident's hallway to invite him. On 09/19/18 at 3:39 P.M. an interview with Resident #47 revealed he received an activity calendar about an hour ago. The resident said he was not aware of the karaoke music activity. He said that might have been fun and he probably would have attended. On 09/09/18 at 3:45 P.M. an interview with State Tested Nurse Aide (STNA) #37 revealed she was assigned to the resident's care. STNA #37 said she was unaware a musical activity was going to occur this afternoon and had not invited the resident to attend this activity. On 09/19/18 at 3:48 P.M., interview with Activity Aide #122 stated she was responsible for inviting the resident to the music karaoke music activity. Activity Aide #122 said she did not invite him as 15 things were going on, time was running short and she did not invite him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 10 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 observation, interview, and medical record review, the facility failed to ensure a resident's edema was monitored and treated as ordered. This affected one (#262) of one residents reviewed for edema. The facility census was 117. Residents Affected - Few Findings include: Medical record review revealed Resident #262 was admitted to the facility on [DATE]. Diagnoses included left hip fracture, atrial fibrillation, hypertension, chronic peripheral insufficiency, and generalized edema. Review of admission Minimum Data Set (MDS) assessment, dated 09/07/18, revealed the resident was independent for cognitive skills for daily decision making, supervision was required with bed mobility, transfers, personal hygiene, and the resident had bilateral lower extremity edema. Review of physician orders dated 09/11/18 revealed daily weights were ordered and to notify the medical doctor if weight gain was greater than five pounds in three days. A physician order, dated 09/13/18, was to apply ace wraps (elastic bandages) when up, on in the morning and off at bedtime. Review of a care plan, initiated on 09/15/18, revealed Resident #262 had a potential for alteration in cardiac output/arrhythmia/cardiorespiratory distress related to atrial fibrillation, congestive heart failure, and hypertension. Interventions included daily weights at 6:00 A.M., and to notify the medical doctor if weight gain was greater than five pounds in three days. Review of treatment administration record (TAR) for September 2018 revealed Resident #262's weights were obtained on 09/12/18, 09/14/18, 09/17/18, and 09/20/18. Weights for 09/13/18, 09/15/18, 09/16/18, 09/18/18, and 09/19/18 were left blank. Observation on 09/18/18 at 10:45 A.M. revealed Resident #262 was up in the wheelchair with feet on the floor without ace wraps in place to legs. Edema was noted to both ankles. Ace wraps were observed folded on arm of recliner chair. Interview with Resident #262 at the time of the observation reported staff still had the remainder of the day to apply the ace wraps and they were never applied prior to getting out of bed. Observation on 09/18/18 at 12:14 P.M. revealed Resident #262 remained up in a wheelchair without ace wraps in place. Interview with Licensed Practical Nurse (LPN) #510 at the time of the observation confirmed Resident #262 did not have ace wraps in place as ordered. Interview on 09/20/18 at 3:47 P.M. with Registered Nurse Assistant Director of Nursing (RNADON) #124 reported all weights obtained for Resident #262 were documented on the TAR and verified weights were not obtained daily as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 11 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 observation, interviews, medical record review, and review of facility policy, the facility failed to ensure a fall was investigated, interventions were implemented and monitored for effectiveness. This affected one (#85) of six residents reviewed for accidents. The facility census was 117. Findings include: Medical record review revealed Resident #85 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, diabetes with neuropathy, and heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 08/20/18, revealed the resident's cognition was intact, decision making, extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and a wheelchair was utilized for mobility. Review of a care plan, initiated 08/13/18, revealed potential for injuries/falls related to advanced aging, impaired decision making abilities, generalized weakness with gait and balance disturbance due to non-weight bearing to right foot, incontinence, use of diuretic, hyperglycemic agent, pain medications, history of falls, and new to environment. Interventions included assist with transfer with use of sliding board or Hoyer into wheelchair as needed, encourage non-skid footwear at all times, monitor safety/preventative devices for application. Instruct on use of adaptive equipment as needed. Observe and report unsafe conditions. Provide a safe environment and therapy as ordered. No interventions had been added to the care plan since 08/24/18. Review of a nursing progress note, dated 09/15/18 at 4:14 P.M., revealed the resident complained of discomfort to her right knee, reported no trauma but she had pain started this morning. No redness, and slight swelling was noted to bilateral lower extremities from knee to toes. An order was obtained for an x-ray to her right knee, which was obtained and negative for fracture. The leg was elevated in a position of comfort. Review of a physician assistant progress note, dated 09/18/18, revealed Resident #85 complained of right knee pain and reported falling on her knee. X-ray was negative for a fracture. The plan was to apply ice to right knee three times daily for three days for pain. The medical record did not include any documentation about the circumstances of the fall or implementation of any additional interventions. Interview on 09/17/18 at approximately 11:32 A.M. with Resident #85 reported she was upset and reported a fall on the night of 09/14/18, upon being transferred to bed which resulted in a bruise to the top of the left hand and right knee pain. Resident #85 reported the State Tested Nursing Assistants (STNAs) rushed the transfer and would not permit her, upon request, from utilizing techniques taught by therapy. The STNAs unexpectedly grabbed her by the pants as the she attempted to stand, prior to obtaining balance, and was unable to support the resident's weight, and the STNAs dropped the resident onto the floor between the night stand and bed. They then picked her up and tossed her back into the bed. Resident #85 reported the STNAs were abusive. Resident #85 reported originally informing the resident council president of the abuse allegation and fall as the resident was unsure whom to report the allegation to and then informed Registered Nurse Supervisor (RNS) #192 about the incident. Resident #85 reported everybody knew about the fall and abuse allegation and Registered Nurse Assistant Director of Nursing (RNADON) #124 questioned the resident about the incident earlier today. Interview with STNA #74 on 09/20/18 at 10:07 A.M. reported being informed during morning report, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 12 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 upon arrival to work on 09/15/18, that Resident #85 had a fall. Level of Harm - Minimal harm or potential for actual harm Interview on 09/20/18 at 1:47 P.M. with RNS #192 reported Resident #85 informed her on 09/15/18 the two STNAs whom helped her transfer the previous night treated her/him rough. RNS #192 reported she contacted the nurse whom had been on duty. The nurse reported Resident #85 had lost balance during a transfer, the STNAs did what they could to try and prevent the resident from falling, grabbed on to the resident to prevent the resident from falling all the way to the floor. Residents Affected - Few Interview on 09/20/18 at 2:44 P.M. with the Director of Nursing (DON) reported Resident #85 did not have any falls at the facility. Interview on 09/20/18 at 2:57 P.M. with RNADON #124 verified there was a report of the resident falling and all falls were investigated. Interview on 09/20/18 at 5:10 P.M. with the Director of Nursing (DON) reported Resident #85's fall was not investigated as she was not aware a fall had occurred, and interventions were not implemented as a result of the fall but were implemented due to the knee injury. The DON reported facility protocol was to investigate all falls, witnessed and unwitnessed including resident reported falls. Review of the facility policy on fall prevention, revised 11/14/17, revealed in the event of a fall, the resident will be assessed for injury by the nurse and an investigation will be initiated to determine a root cause of the fall. A new intervention/change in care plan will be made to reduce the risk of a reoccurrence and/or to prevent injury as indicated. The resident and/or responsible party will participate in the care planning process as able. A interdisciplinary team meeting will be held after all falls to re-evaluate the plan of care and determine the need for further interventions or care plan adjustments. This deficiency substantiates Complaint Number OH00099742. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 13 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of medical record and review of facility policy, the facility failed to ensure a resident received proper catheter care and a catheter was discontinued as ordered. This affected one (#263) of one resident reviewed for catheter. The facility identified four residents (#4, #25, #62 and #263) with catheters at the facility. The census was 117. Findings include: Medical record review revealed Resident #263 was admitted to the facility on [DATE] with diagnoses of right hip fracture, urinary retention, and Alzheimer's disease. Review of the admission Minimum Data Set (MDS) assessment, dated 09/10/18, revealed the resident had severely impaired cognition and had a catheter for urinary retention. Review of the care plan, initiated 09/10/18, revealed Resident #263 was admitted with an indwelling catheter due to urinary retention. Interventions included to keep the foley bag below the level of the bladder at all times. Review of a physician order, dated 09/11/18, revealed an indwelling catheter for urine retention and catheter care every shift. On 09/12/18, a physician was to remove the indwelling catheter and begin voiding trial on 09/19/18, which was marked as completed. Review of a physician progress note, dated 09/17/18, revealed an assessment and plan was discussed with nursing and included ongoing urinary retention, voiding trial to begin on 09/19/18, and after seven days on Flomax (urinary retention medication), to continue Flomax. Observation on 09/18/18 at 11:18 A.M. of Resident #263 with State Tested Nursing Assistants (STNAs) #119 and #121 revealed Resident #263 remained in bed with catheter leg bag attached on top of the left thigh, above the level of the bladder. Both STNA's verified location of the catheter leg bag and provided no additional information. Interview on 09/20/18 at 3:47 P.M. with Registered Nurse Assistant Director of Nursing (RNADON) #124 reported the order to remove the catheter was missed and as a result Resident #263's catheter was not removed and voiding trial was not initiated on 09/19/18 as ordered. Review of the facility's list of residents with catheters revealed Resident #4, #25, #62 and #263 had catheters in place. Review of facility Urinary Catheter policy, revised November 2017, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 14 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 observations, interviews, and record reviews the facility failed to store foods in a safe manner by not dating opened foods. This affected 114 of 117 who receive food from the kitchen (Residents #42, #69, and #90 receive nothing by mouth). Findings include: Observations during the kitchen and kitchenettes tour on 09/17/18 at 10:15 A.M. revealed the Bistro refrigerator contained an undated bowl of mixed fruit, an undated half-full pitcher of lemonade, and several hard-boiled eggs with shells removed in an undated plastic resalable bag. In the air curtain refrigerator, there were two full trays of undated individually covered bowls of sliced pears and one full tray of undated individually covered cups of varying juice flavors. The refrigerator located in the Diamond Unit contained an undated half-full pitcher of of orange juice, an undated half-full pitcher of cranberry juice, an undated and a grocery store bag in the bottom drawer which contained a clear undated bag of what appeared to be two empanadas. An interview of Dietary Manager #150 on 09/17/18 at 10:15 A.M. verified the contents of the refrigerators listed above were undated and opened and stated they all should be dated if opened. Review of a list of residents who received meals from the kitchen revealed Residents #42, #69, and #90 did not receive meals from the kitchen. A review of the facility policy titled, Proper Food Storage, dated 11/01/17, revealed it was important that all foods be stored properly to prevent potential contamination and food borne illnesses. This included securely covering and dating foods. All items not in a dated manufacturer's container, must be dated by the use of a marker or date gun. Once opened, ready to use items were to be dated with the date they were opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 15 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 observations, staff interviews, record reviews, review of manufacturer guidelines, and review of Centers for Disease Control and Prevention guidelines, the facility failed to ensure proper cleaning according to manufacturer instructions of a blood glucose monitor machine used for multiple residents. The facility also failed to ensure staff were knowledgeable of isolation precautions. The facility identified eight residents (Residents #7, #15, #28, #38, #45, #46, #54, and #62) who utilized the glucometer machine and one resident (Resident #24) who was in isolation precautions at the time of the survey. This had the potential to affect all 117 residents residing at the facility. Residents Affected - Many Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus. Observation of Licensed Practical Nurse (LPN) #78 on 09/20/18 at 8:20 A.M. perform a fingerstick glucose on Resident #15 using a Quintec AC blood glucose monitor. LPN #78 placed a blood glucose strip in the monitor, wiped the resident's finger with an alcohol pad, and used a lancet to to obtain the blood sample, placed the monitor with the strip to obtain the blood, and waited for the result. LPN #78 placed the monitor back in the box with the alcohol and gauze pads and returned to the medication cart. LPN #78 then picked up the blood glucose monitor and cleansed it with an alcohol pad. Interview of LPN #78 on 09/20/18 at 8:20 A.M. verified the blood glucose monitor was used on all patients requiring blood glucose monitoring and stated she always cleans the blood glucose monitors with alcohol pads between resident use. LPN #78 verified she did not know the manufacturer cleaning instructions or the facility policy for cleaning the blood glucose monitor. Interview of the Director of Nursing (DON) on 09/20/18 at 9:00 A.M. verified the blood glucose monitor should have been cleaned according to manufacturer instructions with a sanitizing wipe and stated she had trained LPN #78 on the cleaning of the blood glucose monitor two weeks ago. A review of the Quintec AC manufacturer instructions for cleaning revealed all glucometers that were shared between patients must be cleaned and disinfected after use with each patient to help prevent the transmission of bloodborne pathogens. Review of the Nurse Skill Checklist for LPN #78 for Blood Glucose Testing was signed as completed satisfactorily and observed by the DON on 08/29/18. Review of the facility's list of residents who utilized the glucometer machine revealed Residents #7, #15, #28, #38, #45, #46, #54, and #62 utilized the glucometer machine. 2. Medical record review revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included cellulitis and diverticulosis. Review of the admission Minimum Data Set (MDS) assessment, dated 07/06/18, revealed the resident had moderately impaired cognitive skills and required extensive assistance was required with all activities of daily living (ADL's). Review of physician order revealed antibiotics were ordered until 10/11/18 for clostridium difficile (C-diff), a bacterium that caused symptoms ranging from diarrhea to life-threatening inflammation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 16 of 17 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 365712 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookwood Retirement Community 12100 Reed Hartman Highway Cincinnati, OH 45241 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 of the colon. Resident #24 was placed on contact isolation precautions. Level of Harm - Minimal harm or potential for actual harm Observation on 09/18/18 at 9:13 A.M. revealed an isolation cart in the hall outside of Resident #24's room. The cart didn't contain any gowns. Residents Affected - Many Observation on 09/18/18 at 11:28 A.M. revealed Licensed Practical Nurse (LPN) #33 was in Resident #24's room interacting with the resident without any personal protective equipment in place. Interview with LPN #33 upon exiting the room, about what equipment needed to be worn to enter the room, replied she was unsure why Resident #24 had an isolation cart outside the door and reported she would check. At 11:53 A.M., LPN #33 returned and reported Resident #24 was on contact isolation precautions for C-diff and intravenous antibiotics for C-diff and cellulitis. Review of the Centers for Disease Control and Prevention (CDC) guidelines on contact isolation precautions, last revised 02/28/17, revealed to use personal protective equipment appropriately, including gloves and gown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365712 If continuation sheet Page 17 of 17