Inspection·June 10, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure residents received written documentation explaining the reason for transfers to hospital at the time of transfer. This affected two residents (#112 and #119) of two residents reviewed for hospital transfer requirements. The facility census was 123. Findings included: 1. Medical record review for Resident #112 revealed an admission on [DATE] with a discharge on [DATE] and a readmission on [DATE]. Diagnoses that include high blood pressure, stroke, hemiplegia and hemiparesis, epilepsy, kidney failure, vascular dementia, major depressive disorder, osteoarthritis, anxiety, obesity, and history of falls. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was assessed as rarely or never understood. Verbal behaviors were coded one to three days for verbal behaviors directed at others and behaviors not directed at others. Resident #112 requires extensive assist for bed mobility with one staff member, transfers, and toileting with two staff members and limited assist for eating with one staff member. Review of physician orders for Resident #112 for the month of May 2021 revealed an order dated 04/29/21 to send resident to emergency room for evaluation. Review of progress notes for Resident #112 dated 05/01/21 at 5:58 P.M., revealed resident was noted with altered mental status, physician was notified and an order to sent resident to the emergency room was obtained. Power of attorney was notified. Observation on 06/01/21 3:44 P.M., of resident revealed a well-groomed appropriately dressed resident resting in bed in her room. Call light was within reach. Interview with Licensed Practical Nurse #56 on 06/01/21 at 2:48 P.M., stated when a resident is transferred to the hospital, they sent a face sheet, a medication list, a code status, and a bed hold policy. If the resident is confused, they do not give them a notification of why they are being transferred in writing. Interview with Licensed Practical Nurse #25 on 06/01/21 3:04 P.M., verified she did not send a bed hold policy with the resident or a written document as to why the resident was being sent to the hospital on [DATE]. Further stated resident is confused and would not understand document. 2. Review of the closed medical record for Resident #119 revealed she was admitted on [DATE] and discharged on 05/02/21. Diagnoses included: muscle weakness, unsteadiness on feet, history of falling, osteoarthritis, pulmonary fibrosis, disorientation, anxiety, anemia, cataract extraction status right eye, acquired absence of both cervix and uterus, and hypertension. Review of the nursing note dated 05/03/21 at 1:58 P.M., revealed the resident was transferred to the emergency department of the hospital. Further review of the record revealed there were no notices of transfer in the resident's charts and the resident was responsible for herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 2 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/02/21 at 11:53 A.M., revealed the Director of Nursing (DON) confirmed the resident did not received written notification of the discharge. Review of facility policy titled Bed Holds and Returns, dated 03/2017, revealed the facility failed to implement the policy as written. Number three stated prior to a transfer written information will be given to the resident and the resident representative that explains in detail the rights and limitations of the resident. Event ID: Facility ID: 365714 If continuation sheet Page 3 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of policy, the facility failed to provide written notification to the resident or resident's representative of their bed hold policy. This affected one (#119) of four reviewed for bed holds. The census was 123. Findings include: Review of the closed record review for Resident #119 revealed she was admitted on [DATE] and discharged on 05/02/21. Diagnoses included muscle weakness, unsteadiness on feet, history of falling, osteoarthritis, pulmonary fibrosis, disorientation, anxiety, anemia, cataract extraction status right eye, acquired absence of both cervix and uterus, and hypertension. Review of the nursing note, dated 05/01/21 at 9:30 P.M., revealed the resident was transferred to the emergency department of the hospital. Further review of the record revealed there were no notices of the bed hold policy in the resident's charts and the resident was responsible for herself. Interview on 06/02/21 at 11:53 A.M., revealed the Director of Nursing (DON) confirmed the resident did not receive the bed hold policy. Review of policy titled, Bed-Holds and Returns revised March 2017 revealed prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 4 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 0641 Ensure each resident receives an accurate assessment. 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 Pre-admission Screening and Resident Review (PASRR) and review of the Centers of Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set assessments were accurate. This affected two (#48 and #16) of 24 residents assessments reviewed for accuracy. The facility census was 123. Residents Affected - Few Findings include: 1. Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint replacement, atrial septal defect, heart valve replacement, gastro-esophageal reflux disease and hyperglycemia. Review of the Modification of Medicare - 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was assessed as moderately impaired cognitive level and always incontinent of bladder. The MDS assessment was silent for the use of an indwelling Foley catheter. Review of the deleted and completed electronic physician orders and the telephone orders were silent for an indwelling Foley catheter prior to a telephone order dated 04/14/21 to insert a Foley catheter one time only with no diagnoses listed. Observations on 05/26/21 at 11:00 A.M., revealed Resident #48 lying in bed with the television on, the Foley catheter bag was attached to side of bed draining cloudy urine. Interview on 06/01/21 at 9:12 A.M. with Certified Nurse Aide # 58 revealed the resident had the indwelling Foley catheter when she returned from the hospital on [DATE]. Interview on 06/02/21 at 8:37 A.M., with the Director of Nursing confirmed the MDS assessment was silent for the use of an indwelling Foley catheter. 2. Medical record review for Resident #16 revealed an admission date on 06/12/15, with diagnoses including unspecified intellectual disabilities, cerebral palsy, high blood pressure, anxiety, hypotension, dental caries, hypothyroidism, major depressive disorder, hearing loss, repeated falls, long term drug therapy seizure disorder and personal history of infectious parasitic disease. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #16 revealed resident was admitted from an acute hospital without intellectual disabilities. Resident was coded as rarely or never understood. Resident #16 requires supervision for bed mobility, transfers, and toileting. Eating was coded as extensive assist. Review of plan of care for Resident #16 dated 12/28/16 revealed resident was unable to care for himself independently. Requires 24 hour supervision and will remain a long term care resident due to diagnoses of depression anxiety and mental retardation and developmental disabilities. Resident is at risk for altered mood and well-being due to medical diagnosis of depression, anxiety and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 5 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 0641 Level of Harm - Minimal harm or potential for actual harm developmental delays. Resident can become anxious and restless at times. May refuse care and have attention seeking behaviors such as putting himself on the floor, banging head, slamming doors, messing with gastronomy-tube and faking seizures. Interventions include accommodate my preferences in regard to tube feeding, encourage me to interact with others, redirect my behavior as it occurs and refer for services for the psychologist or psychiatrist as needed. Residents Affected - Few Review of the PASARR (a tool used to help ensure individuals are not inappropriately placed in a nursing home for long term care) for Resident #16 dated 03/22/12 revealed resident had indications of mental retardation and developmental disability. Interview with Licensed Practical Nurse (LPN) #122 on 05/27/21 at 10:43 A.M., verified MDS section 1500 was wrong. Further confirmed the resident has a diagnosis of intellectual disability. Review of the Centers of Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0 (instructions for the completion of the Minimum Data Set) page A-22 revealed Section A of the MDS should be completed if a Level II PASRR determines a resident has mental disability. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #16 with a modification completed on 06/01/21 revealed resident is currently considered by the state level II PASRR to have a serious mental illness and or intellectually disability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 6 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission. This affected two (#33, and #119) of four residents reviewed for new admission. The census was 123. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses including dizziness and giddiness, age-related osteoporosis without current pathological fracture, Alzheimer's Disease and muscle weakness. Further review revealed Resident #33 did not have a baseline care plan implemented. 2. Review closed record review for Resident #119 was admitted on [DATE], with diagnoses including muscle weakness, unsteadiness on feet, history of falling, osteoarthritis, pulmonary fibrosis, disorientation, anxiety, anemia, cataract extraction status right eye, acquired absence of both cervix and uterus, and hypertension. Further review revealed Resident #119 did not have a baseline care plan implemented. Interview with the Director of Nursing on 06/02/21 at 12:15 P.M., confirmed baseline care plans was not implemented within 48 hours of admission for the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 7 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, the facility failed to initiate comprehensive care plans for residents. This affected two (#48 and #66) of 24 sampled residents. The facility census was 123. Findings included: 1. Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint replacement, atrial septal defect, heart valve replacement, gastro-esophageal reflux disease and hyperglycemia. Review of the 5-day Minimum Date Set (MDS) assessment dated [DATE] revealed no diagnoses for and no use of an indwelling Foley catheter. Review of active plans of care for Resident #48 revealed an urinary/bowel incontinence care plan, dated 03/16/21, due to cerebral vascular accident and right sided weakness, impaired mobility, and inability to communicate needs. The care plans were silent for the use of an indwelling Foley catheter. Review of the deleted and completed electronic physician orders and the telephone orders were silent for an indwelling Foley catheter prior to a telephone order dated 04/14/21 to insert a Foley catheter one time only with no diagnoses listed. Review of the nursing progress notes dated 04/14/2021 at 12:19 P.M., revealed the Registered Nurse (RN) removed the current Foley catheter and sediment was present. The RN then inserted a 16 french (FR) 10 milliliter (ML) Foley catheter and it drained clear yellow urine. Observations on 05/26/21 at 11:00 A.M., revealed Resident #48 lying in bed with the television on, the Foley catheter bag was attached to side of bed draining cloudy urine. Observations on 06/01/21 at 9:12 A.M., of catheter care for Resident #48 completed by Certified Nurse Aide (CNA) #58 revealed no issues with the completion of catheter care. Interview on 06/01/21 at 9:12 A.M., with Certified Nurse Aide #58 revealed the resident had the indwelling Foley catheter when she returned from the hospital on [DATE]. Interview on 06/02/21 at 8:37 A.M., with the Director of Nursing confirmed there was no plan of care a Foley catheter and that a catheter care order was put in on 06/01/21. 2. Review of Resident #66's medical record revealed an admission date of 03/31/21 and a re-admission date of 04/27/21, with diagnoses including malignant neoplasm of the prostate with malignant neoplasm of the bone, difficulty walking, pathological fractures of the right humrerous and left femur, weakness, bacterial pneumonia, pain, type two diabetes, obesity, anemia, disorders of the adrenal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 8 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 0656 gland, acute kidney failure, hyperlipidemia, and a history of polymyelitis. Level of Harm - Minimal harm or potential for actual harm Review of the Medicare -5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was assessment as cognitive intact with no cognitive issues and no mood or behavior issues. Resident #66 was assessed for minimal one person assist for bed mobility, transfers, ambulation, toileting and maximum one person assist for bathing. Resident #66 was always continent of bladder and bowel. Resident #66 used a walker or wheel chair for mobility. Residents Affected - Few Review of Resident #66's plans of care revealed all the care plans were canceled prior the resident's return from the hospital on [DATE] and reinitiated on 06/02/21, during the survey. Interview on 05/25/21 at 12:12 P.M., with Resident #66, stated I have never attended care conference here. Since my leg and arm got broke I have not walked since. The nurse aides help me with bathing. Interview on 06/02/21 at 8:21 A.M., with the Director of Nursing confirmed the care plans were all canceled when Resident #66 returned from the hospital and not reactivated until 06/02/21 when brought to the attention of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 9 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, resident family member and resident interviews, and policy review, the facility failed to include residents in initial and quarterly care conferences when planning the residents care. This affected three (#55, #66, and #75) of five sampled residents for care planning. The facility census was 123. Findings included: 1. Review of Resident #66's medical record revealed an admission date of 03/31/21 and a re-admission date of 04/27/21, with diagnoses including malignant neoplasm of the prostate with malignant neoplasm of the bone, difficulty walking, pathological fractures of the right humrerous and left femur, weakness, bacterial pneumonia, pain, type two diabetes, obesity, anemia, disorders of the adrenal gland, acute kidney failure, hyperlipidemia, and a history of polymyelitis. Review of the Medicare -5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was assessment as cognitive intact with no cognitive issues and no mood or behavior issues. Resident #66 was assessed for minimal one person assist for bed mobility, transfers, ambulation, toileting and maximum one person assist for bathing. Resident #66 was always continent of bladder and bowel. Resident #66 used a walker or wheel chair for mobility. Review of Resident #66's plans of care revealed all the care plans were canceled prior the resident's return from the hospital on [DATE] and reinitiated on 06/02/21, during the survey. Interview on 05/25/21 at 12:12 P.M., with Resident #66, stated I have never attended care conference here. Since my leg and arm got broke I have not walked since. The nurse aides help me with bathing. Interview on 06/02/21 at 8:21 A.M., with the Director of Nursing confirmed the record was silent for any care conference documented for Resident #66. 2. Review of Resident #75's medical record revealed an admission on [DATE], with diagnoses including: hip fracture, pain in hip, fatigue, acute kidney failure, diabetes, chronic respiratory failure, congestive obstructive pulmonary disease, asthma, vascular dementia, convulsions, heart failure, chronic atrial fibrillation, heart disease, psychosis, restlessness and agitation, osteoarthritis, anemia, transient ischemic attack and stroke, obesity, retention of urine. Review of quarterly Minimum Data Set (MDS) assessment for Resident #75 dated 04/10/21, revealed an impaired cognition. Resident requires extensive assist from two staff members for bed mobility, transfers, and toileting. No behaviors were coded. Resident is supervised for eating. Resident is coded as always incontinent of bladder and frequently incontinent of bowel. Resident has had two falls with no injuries since the last assessment. Resident receives injections, antipsychotics, antidepressants, anticoagulants and opiods during with assessment period. Resident currently receiving hospice benefits. Review of plan of care for Resident #75 dated 05/12/19, with revisions on 04/15/20 and 06/04/20, revealed resident is at risk for falls due to confusion, weakness, unsteady gait and balance, needing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 10 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistance with transfers, pain, poor safety awareness, medications, comorbidities. I have history of sleeping on the side of the bed. Interventions include assist grab bar to be for transfers and bed mobility, call light with in reach, bolster to bed, dycem to wheelchair, bed in low position, mat to floor, medication evaluation Review of progress notes for Resident #75 from 05/20/20 to 06/03/21, was silent for any meeting with the resident or resident representative. Review of the facility's MDS care conference calendar revealed Resident #75 was scheduled to receive a letter from the facility requesting a meeting on 01/04/21 and again on 04/10/21. Observation of the resident on 05/27/21 at 4:26 P.M., revealed interventions in place per the plan of care. Resident #75 is sitting in her room in her wheelchair well-groomed and appropriately dressed. Interview with Resident #75's family member on 05/27/21 at 3:15 P.M., stated he has not had a meeting with multiple disciplinaries from the facility regarding Resident #75 plan of care. Interview with the DON on 06/02/21 at 6:01 P.M., stated the Administrative Assistant #79 for the Administrator mails out a letter to the family or the resident representative asking them to call the facility. An appointment for a care conference would be scheduled after a MDS has been completed. The DON, further stated there is not any follow up call to the letter and no notes are entered into the the system regarding the mailing of the letter. The facility does not have a day dedicated to the care plan meeting as the facility tries to accommodate the family's schedule. The social service staff members are supposed to enter a progress notes in the electronic health record. Interview on 06/03/21 at 10:50 A.M., with Social Service Designee (SSD) #85 verified the progress notes were silent for any care conference for Resident #75 since her admission on [DATE]. SSD #85, further stated no communication regarding the invitation to the care conference or the decline of the invitation was documented in the progress notes. 3. Review of Resident #55's medical record revealed an admission date of 10/02/17, with diagnoses including chronic kidney disease, hypertension, history of falls, acute kidney failure, post-traumatic stress disorder, psychosis, asthma, bipolar disorder, major depression, schizoaffective disorder, irritable bowel syndrome, repeated falls, weakness, constipation, old heart attack, and transient ischemic attack (stroke like attack). Review of quarterly MDS dated [DATE] for Resident #55 revealed impaired cognition. Resident #55 required extensive assist for bed mobility, transfers, and toileting. Resident is supervision for eating. Review of the facility's care plan conference calendar revealed the Resident #55 was scheduled for a meeting on 03/17/21 and again on 04/04/21. Review of the electronic health record MDS section for Resident #55 revealed a Significant change assessment was completed on 12/04/20, a quarterly MDS assessment was completed on 01/11/21 and a quarterly assessment was completed on 04/04/21. Review of progress notes for Resident #55 dated 11/30/20 through 06/01/21, are silent for care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 11 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 conference meetings with resident or interdisciplinary team members. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #55 on 05/27/21 stated she has not received an invitation to attend a care conference for a long time. Residents Affected - Few Interview with Social Services Designee (SSD) #85 on 06/01/21 at 1:55 P.M., stated if the family does not respond to the letter sent to them, the facility just has a meeting. SSD #85, further stated she does not document in the progress notes if the family does not respond to an invitation. Additionally, stating after reviewing the progress notes for Resident #55, there was not a note regarding care conferences for the last MDS review on 04/04/21. SSD #85 is unable to recall if the resident was invited or not. Interview with the DON on 06/01/21 at 2:30 P.M., stated she would look for documentation for conferences but stated the social worker should be entering the care conferences into the residents' progress notes. Review of the undated policy titled, Care Planning- Interdisciplinary Team stated the resident and residents' family are encouraged to participate in the development of and revisions to the resident's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 12 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 record review, observation and staff interviews, the facility failed to obtain a physician order for the use of an indwelling Foley catheter and a supporting diagnosis. This affected one (#48) of 24 sampled residents. The facility identified seven residents with indwelling Foley catheters. The facility census was 123. Findings included: Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint replacement, atrial septal defect, heart valve replacement, gastro-esophageal reflux disease and hyperglycemia. Review of the 5-day Minimum Date Set (MDS) assessment dated [DATE] revealed no diagnoses for and no use of an indwelling Foley catheter. Review of the deleted and completed electronic physician orders and the telephone orders were silent for an indwelling Foley catheter prior to a telephone order dated 04/14/21 to insert a Foley catheter one time only with no diagnoses listed. Review of the nursing progress notes dated 04/14/2021 at 12:19 P.M., revealed the Registered Nurse (RN) removed the current Foley catheter and sediment was present. The RN then inserted a 16 french (FR) 10 milliliter (ML) Foley catheter and it drained clear yellow urine. Observations on 05/26/21 at 11:00 A.M., revealed Resident #48 lying in bed with the television on, the Foley catheter bag was attached to side of bed draining cloudy urine. Observations on 06/01/21 at 9:12 A.M., of catheter care for Resident #48 completed by Certified Nurse Aide (CNA) #58 revealed no issues with the completion of catheter care. Interview on 06/01/21 at 9:12 A.M., with Certified Nurse Aide # 58 revealed the resident had the indwelling Foley catheter when she returned from the hospital on [DATE]. Interview on 06/02/21 at 8:37 A.M., with the Director of Nursing (DON) confirmed there was no order for a Foley catheter until 04/14/21 and that a catheter care order was put in on 06/01/21. The DON verified there was not a diagnosis to support the use of the catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 13 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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, observations, staff interviews and policy review, the facility failed to ensure residents receiving psychoactive medications were being adequately monitored for adverse side effects. This affected two (#16 and #75) of five reviewed for psychoactive medication usage. The facility census was 123. Residents Affected - Few Findings Include: 1. Medical record review for Resident #16 revealed an admission date on 06/12/15 with diagnoses including unspecified intellectual disabilities, cerebral palsy, high blood pressure, anxiety, hypotension, dental caries, hypothyroidism, major depressive disorder, hearing loss, repeated falls, long term drug therapy and personal history of infectious and parasitic disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed resident was coded as rarely or never understood. No behaviors were assessed during the look back period. Resident #16 requires supervision for bed mobility, transfers, and toileting. Eating was coded as extensive assist. Resident #16 received antipsychotic and antidepressant medication during the look back period. Review of the physician orders for Resident #16 revealed an order, an order dated 03/11/21 for Sertraline hydrochloride (HCl) Concentrate 20 milligram (mg) per milliliter (ml) give 2.5 ml via Gastrostomy Tube (g-tube) one time a day related to major depressive disorder, an order for Abilify tablet 2 mg give 2 mg via G-Tube one time a day for schizoaffective disorder and depression dated 03/10/21, an order dated 09/10/20 for Lorazepam Intensol Concentrate 2 mg/ml give 0.5 mg via G-Tube every 8 hours as needed for seizures and an order dated 05/24/21 to monitor/record/report to Medical Doctor (MD) as needed side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS) such as shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person. Review of plan of care for Resident #16 dated 03/18/20 revealed resident uses antianxiety medications related to seizures. Interventions include follow up with neurologist as ordered, follow seizure precautions per policy, medications as ordered and monitor for effectiveness and adverse side effects of medication and alert physician. Review of Resident #16's plan of care for psychotropic medication related to depression and schizoaffective disorder dated 02/24/21. Interventions include Aims test every six months, educate resident about the risk and benefits of medication, GDR will be done per protocol and pharmacy recommendations. Psychoactive drug assessments will be done quarterly and prn. Monitor me for side effects including lethargy and falls and notify md as needed. Observation of Resident #16 on 05/27/21 at 10:37 A.M., revealed resident propelling his wheelchair in hallway. Resident was using grip hand exercise equipment in his right hand without difficulty, no concerns were identified. Interview with Licensed Practical Nurse (LPN) #56 on 06/02/21 at 10:45 A.M., stated there was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 14 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any paper documents that nurses were utilizing to monitor resident for adverse side effects of psychoactive medication. Further stated if any side effects are noted they will notify the physician and chart in the progress notes. Interview with Unit Manager #99 on 06/03/21 at 10:00 A.M., verified the facility added the monitoring orders to the Medication Administration Record on 05/24/21, when it was noticed during an audit. Further verified no additional documentation was available for review. Interview on 06/02/21 at 2:31 P.M., with the Director of Nursing (DON) verified the facility did not have any daily documentation for monitoring potential adverse effects in place until 05/24/21. Further stated during an audit it was noted the Medication admission Record (MAR) was silent for an order to observe and document daily for any signs and symptoms of adverse side effect every shift and was added at that time. 2. Medical record review for Resident #75 revealed an admission on [DATE] with hip fracture, pain in hip, fatigue, acute kidney failure, diabetes, anxiety disorder, chronic respiratory failure, congestive obstructive pulmonary disease, asthma, vascular dementia, convulsions, heart failure, chronic atrial fibrillation, heart disease, psychosis, restlessness and agitation, osteoarthritis, anemia, transient ischemic attack and stroke, obesity, retention of urine, psychosis, and major depressive disorder. Review of quarterly Minimum Data Set (MDS) for Resident #75 dated 04/10/21 revealed an impaired cognition. Resident requires extensive assist from two staff members for bed mobility, transfers, and toileting. Resident is supervised for eating. Resident was assessed as having no behaviors during the assessment period. Resident received antipsychotics and antidepressants daily during the look back period. Review of plan of care dated 05/19/21 for Resident #75 revealed resident is at risk for side effects due to the use of antidepressants, antipsychotics, and anxiolytics. Interventions include behaviors and adverse effects are monitored and recorded, medical doctor (MD) will be made of adverse effects, monitor for side effects including lethargy and falls and notify MD if noted and monitor/record/report to MD as needed side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, extrapyramidal symptoms (EPS) such as shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person. Review of physician orders for Resident #75 revealed and order dated 02/18/2021 for Cymbalta Capsule Delayed Release Particles 30 milligrams (mg) give 1 capsule by mouth one time a day for major depressive disorder, Abilify Tablet 5 mg give 1 tablet by mouth one time a day related for anxiety disorder dated 04/08/21, and an order dated 05/24/21 to monitor/record/report to MD as needed side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. Observation on 05/24/21 at 1:30 P.M., of Resident #75 revealed a well-groomed alert female resident sitting in her wheelchair in her room. No concerns identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 15 of 16 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 365714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Leonard Hcc 8100 Clyo Road Centerville, OH 45458 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #56 on 06/02/21 at 10:45 A.M., stated there was not any paper documents that nurses were utilizing to monitor resident for adverse side effects of psychoactive medication. Further stated if any side effects are noted they will notify the physician and chart in the progress notes. Interview with Unit Manager #99 on 06/03/21 at 10:00 A.M., verified the facility added the monitoring orders to the Medication Administration Record (MAR) on 05/24/21, when it was noticed during an audit. Further verified no additional documentation was available for review. Interview on 06/02/21 at 2:31 P.M. with the Director of Nursing (DON) verified the facility did not have any daily documentation for monitoring potential adverse effects in place until 05/24/21. Further stated during an audit it was noted the Medication admission Record (MAR) was silent for an order to observe and document daily for any signs and symptoms of adverse side effect every shift and was added at that time. Review of facility policy titled Antipsychotic Medication Use, dated 12/2016, revealed the facility did not implemented the policy as written. Number 17 states the nursing staff will monitor for adverse side effects and adverse consequences of taking psychoactive medications. The following items will be monitored constipation, blurred vision, dry mouth, urinary retention, sedation, orthostatic hypotension, arrhythmias, increase in total cholesterol, unstable blood sugars, stroke, tardive dyskinesia (abnormal muscle movements), and ESP. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 16 of 16