Inspection·March 20, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The Administrator stated he had completed an investigation and filed a Self-Reported Incident (SRI) involving Resident #10 and her daughter for alleged physical abuse on 03/08/24. The DON stated she did not believe Resident#10's daughter intended any harm to Resident #10 and stated staff were blowing things out of proportion because they did not like how the daughter interacted with the resident. The DON and Administrator agreed that if a staff member had overheard anyone making a statement, Why don't you just die? to a resident, that would have been considered verbal abuse. During an interview on 03/19/24 at 1:57 P.M., LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. Review of policy titled, Abuse, Neglect, And Exploitation, dated 10/24/22 revealed staff were educated to identify possible indicators of abuse including staff reports of abuse, physical injury to a resident from an unknown source, verbal abuse of a resident overheard, and physical abuse of a resident observed. The facility made efforts to ensure all residents were protected from abuse by responding immediately to protect the alleged victim from additional abuse. This deficiency represents non-compliance investigated under Complaint Number OH00152007. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 2 of 6 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 03/20/2024 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 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 review of the medical record, staff interviews, and policy review, the facility staff failed to report allegations of abuse in a timely manner. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/24. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State Tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate a source of bleeding. The daughter was observed to be stuffing goldfish crackers into the resident's mouth and trying to give soda to help the resident swallow. The soda was spilling down the resident's chest. Further review of the medical record revealed no documentation of an incident between Resident #10 and the resident's daughter on 03/01/24. During an interview on 03/18/24 at 2:50 P.M., STNA #131 stated she had not been present when the incident on 02/24/24 occurred, however, on 03/01/2025 around 5:30 P.M., she witnessed Resident #10's daughter trying to force noodles into the back of the resident's mouth with a butter knife. STNA #131 stated she reported the observation to the nurse. STNA #131 and the nurse returned to the resident 's room and overheard Resident #10's daughter screaming at the resident and crying hysterically. STNA #10 verified staff did not intervene or ask the resident's daughter to leave for either incident. During an interview on 03/19/24 at 4:51 P.M., LPN #106 verified on 02/24/24, an aide saw and reported Resident #10's daughter was forcibly shoving food into the resident's mouth and the facility took no action at the time to remove the family member from the resident's room. LPN #106 stated a second incident happened three weeks ago, on 03/01/24 at dinnertime when Resident #10's daughter had a butter knife and was trying to push noodles down Resident #10's throat. LPN #106 went to the room with STNA #131 and heard Resident #10's daughter scream at the resident, Why don't you just die? repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 3 of 6 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 03/20/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The DON stated she did not receive any written witness statements from staff regarding an incident of alleged abuse on 03/01/24. During an interview on 03/19/24 at 1:51 P.M., the Executive Director stated he was not notified and was unaware of an incident of alleged abuse which occurred on 03/01/24 involving Resident #10 and her daughter. During an interview on 03/19/24 at 1:57 P.M. LPN #106 stated UM #25 told her, STNA #131, and LPN #140 to write statements before leaving and place them under the door to the DON's office. LPN #106 stated she documented the incident in a progress note in Resident #10's medical record. LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. Review of Self-Reported Incidents (SRI) revealed no SRI completed for incidents between Resident #10 and the resident's daughter on 02/24/24 and 03/01/24. Review of policy titled, Abuse, Neglect, And Exploitation, dated 10/24/2022 revealed all allegations involving abuse were reported to the administrator within two hours after the allegation was made. This deficiency represents non-compliance investigated under Complaint Number OH00152007. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 4 of 6 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 03/20/2024 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 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 medical record review, staff interviews, and policy review, the facility failed to investigate allegations of abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/24. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State Tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate a source of bleeding. The daughter was observed to be stuffing goldfish crackers into the resident's mouth and trying to give soda to help the resident swallow. The soda was spilling down the resident's chest. Further review of the medical record revealed no documentation of an incident between Resident #10 and the resident's daughter on 03/01/24. During an interview on 03/18/24 at 2:50 P.M., STNA #131 stated she had not been present when the incident on 02/24/24 occurred, however, on 03/01/2025 around 5:30 P.M., she witnessed Resident #10's daughter trying to force noodles into the back of the resident's mouth with a butter knife. STNA #131 stated she reported the observation to the nurse. STNA #131 and the nurse returned to the resident 's room and overheard Resident #10's daughter screaming at the resident and crying hysterically. STNA #10 verified staff did not intervene or ask the resident's daughter to leave for either incident. During an interview on 03/19/24 at 4:51 P.M., LPN #106 verified on 02/24/24, an aide saw and reported Resident #10's daughter was forcibly shoving food into the resident's mouth and the facility took no action at the time to remove the family member from the resident's room. LPN #106 stated a second incident happened three weeks ago, on 03/01/24 at dinnertime when Resident #10's daughter had a butter knife and was trying to push noodles down Resident #10's throat. LPN #106 went to the room with STNA #131 and heard Resident #10's daughter scream at the resident, Why don't you just die? repeatedly. LPN #106 stated she made a voice recording of this incident and and played it for supervisor, Unit Manager (UM) #25. LPN #106 stated she entered the room and asked if everything was ok. LPN #106 stated she confronted the family member about her behavior, told the family member the behavior was unacceptable, but left the room with the family member still seated at the resident's bedside. During an interview on 03/19/24 at 8:56 A.M., UM #25 stated on 03/01/24 she was working an assignment on the evening shift. STNA #131 reported shortly after dinner she witnessed Resident #10's daughter trying to force the resident to eat and put a butter knife in the patient's mouth. About 20 minutes later, LPN #106 reported something about the knife and being held to Resident #10's throat. UM #25 stated she was busy passing medications and did not go to check on the patient or intervene in any way except to text the Director of Nursing (DON), who had already left for the evening. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 5 of 6 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 03/20/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few texted back she was already aware and had contacted the Executive Director (ED). UM #25 stated she did not call campus security to have the family member removed because she did not think it rose to that level. UM #25 stated at the time it was reported to her, the incident was over, and she was not concerned about the resident's safety at that time. The aide reported the incident on her way to take trash out after dinner was already over. UM #25 stated she walked by the resident's room and peaked in around 6:00 P.M. and Resident #10 was in her room alone. It would have been handled differently had it been reported staff was treating a patient that way. UM #25 stated she did not feel the need to intervene because the staff made conflicting statements about what had happened and UM #25 was too busy to go because she was involved with a fall at the time. UM #25 stated she was never questioned by management about the incident and verified she did not document the incident. During interviews on 03/19/24 at 9:48 A.M., the Administrator and DON each stated they were unaware of any incident of alleged abuse with Resident #10 on 03/01/24. The DON stated she did not receive any written witness statements from staff regarding an incident of alleged abuse on 03/01/24. During an interview on 03/19/24 at 1:51 P.M., the Executive Director stated he was not notified and was unaware of an incident of alleged abuse which occurred on 03/01/24 involving Resident #10 and her daughter. During an interview on 03/19/24 at 1:57 P.M. LPN #106 stated UM #25 told her, STNA #131, and LPN #140 to write statements before leaving and place them under the door to the DON's office. LPN #106 stated she documented the incident in a progress note in Resident #10's medical record. LPN #106 verified there was no progress note in Resident #10's medical record regarding the incident on 03/01/24. During interviews on 03/20/24 at 10:10 A.M., the Administrator and DON stated they could not investigate allegations of abuse if staff did not report allegations of abuse to them. When asked, the DON confirmed nursing management were responsible to review progress notes routinely. The DON confirmed the nursing progress note on 02/24/24, which documented Resident #10 was heard screaming, staff witnessed food being forced into Resident #10's mouth, and there was bleeding from an injury of unknown source, contained indications of potential physical abuse that was never investigated. Review of Self-Reported Incidents (SRI) revealed no SRI completed for an incident between Resident #10 and the resident's daughter on 02/24/24 and 03/01/24 indicating no investigations were completed. Review of the policy titled, Abuse, Neglect, And Exploitation, dated 10/24/22 revealed staff were educated to identify different types of abuse and possible indictors of abuse included the physical injury of a resident from an unknown source, verbal abuse of a resident overhead, and physical abuse of a resident observed. All allegations involving abuse were immediately investigated to determine if abuse had occurred, to what extent abuse had occurred, and why abuse had occurred. This deficiency represents non-compliance investigated under Complaint Number OH00152007. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365714 If continuation sheet Page 6 of 6