Inspection·September 8, 2021

F 0553 the past 12 months. Level of Harm - Minimal harm or potential for actual harm During interview on 08/23/21 at 1:23 P.M., Resident #216 reported not remembering being asked to attend plan of care conferences. Residents Affected - Some During interview on 08/25/21 at 4:00 P.M., Licensed Social Worker (LSW) #43 stated she offered residents the opportunity to participate in their plan of care conferences. She stated when residents refuse to participate, she documents it as well in their electronic medical records. LSW #43 verified there was no documentation in the electronic medical records offering Residents #19, #24, #53, and #216 to participate in plan of care conferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 2 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure a motorized wheelchair was repaired in a timely manner. This affected one resident (Resident #19) of one resident reviewed for accommodation of needs. Census was 74. Residents Affected - Few Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included but not limited to chronic obstructive pulmonary disease, shortness of breath, diabetes mellitus due to underlying condition with hypoglycemia without coma, type two diabetes, mood disorder, periodic paralysis, hypertension, unspecified glaucoma stage, pruritus, chronic pain, and sensorineural hearing loss bilateral. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/21, revealed the resident was cognitively intact for decisions, having clear speech, understand others, others understand him and total dependent with activities of daily living with two persons for physical assist. Resident #19 has impairment on left side of body and uses a mobilized wheelchair. Nursing notes dated 11/13/2020 at 12:01 P.M., revealed Resident #19 was seen by Speech Therapy (ST) this shift. New order received. Resident to be up in wheelchair for all meals. Resident added to Get Up List. Resident aware. Review physician orders dated 11/13/20 revealed Resident #19 to be in wheelchair for all meals every day and night shift. Review of the plan of care dated 01/04/21 revealed Resident #19 has an ADL self-care performance deficit resulted to disease process hemiplegia hemiparalysis, and impaired balance. Resident #19 will maintain current level of function through next review date. Observations on 08/23/21 at 12:15 P.M., on 08/23/21 at 5:30 P.M., and on 08/24/21 at 8:30 A.M., revealed Resident #19 was lying in bed eating his meals in a hospital gown. There was no wheelchair in resident's room. During interview on 08/24/21 at 10:45 A.M., Resident #19 stated he had a motorized wheelchair when he was admitted in November 2020, but the battery went out shortly later. Resident #19 stated he normally likes staying in his room most of the time but misses his wheelchair because he was able to go outside and participate in activities when he felt like it. He said he was tired of being in his room all the time and he told the administrator about his situation. It has been nine months and no one has done anything about his wheelchair or his battery and he does not know where the wheelchair is located. During interview on 08/26/21 at 11:28 A.M., the Administrator stated she speaks to Resident #19 all the time and stated he has not mentioned needing a battery for his wheelchair. She stated the facility investigated and CareSource Insurance denied services to repair the wheelchair. The Administrator was unable to provide documentation of the investigation or denial of services by the insurance company. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 3 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 0558 During interview on 08/26/21 at 1:00 P.M., Maintenance Supervisor (MS) #1 stated he had not received an order to replace a battery in a wheelchair. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 4 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and policy, the facility failed to provide ensure assistance to dependent residents on staff for grooming. This affected one resident (#57) of four reviewed for personal care. The facility census was 74. Residents Affected - Few Findings include: Review of the medical record revealed Resident #57 was admitted on [DATE]. Diagnoses included but not limited to gatro-esophageal reflux disease without esophagitis, hypertension, atrial fibrillation, autistic disorder, altered mental status, abnormalities of gait and mobility, sensorineural hearing loss, bilateral, unspecified lack of expected normal physiological development in childhood, retention of urine, hyperlipidemia, cystostomy, obstructive and reflux uropathy, major depressive disorder, and overactive bladder. Review quarterly Minimum Data Set (MDS) dated [DATE] for modification of admission revealed Resident #57 had severe cognitive impairment and required one-person physical assist for bathing and personal hygiene. Review of Resident #57's electronic record revealed showers were scheduled to be given on Tuesdays, Thursdays and Saturdays. Review of Resident #57's progress notes revealed no documented evidence shaving (personal hygiene) was refused. Interview on 08/23/21 at 12:32 P.M., revealed Resident #57 reported he would like to be shaved. Observations on 08/23/21 from 12:32 P.M., to 08/25/21 3:53 P.M., revealed facial hairs on Resident #57's face. Interview on 08/25/21 at 4:12 P.M., revealed State Tested Nursing Aide (STNA) #67 reported the facility Resident #57 was given a shower on 08/24/21. STNA #67 reported showers consisted of shaving unless the resident refuses and provide nail care as well unless the resident refuses. STNA #67 denied any documentation of Resident #57 denying being shaved. Reviewed policy titled, Personal Bathing and Shower dated 05/30/19; revealed activities of daily living consist of grooming. Men should be shaved during bathing process. Based on medical record review, observations, interviews and facility's policies, the facility failed to ensure bath/showers were provided according to the resident choice. This affected two residents (#19 and #219) of two residents reviewed for choices. Census was 74. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included but not limited to chronic obstructive pulmonary disease, shortness of breath, hemiplegia ad hemiparesis following cerebral infarction affecting left non-dominant side, need for assistance with personal care, periodic paralysis, diabetes mellitus due to underlying condition with hypoglycemia without (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 5 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few coma, type two diabetes, mood disorder, hypertension, unspecified glaucoma stage, pruritus, chronic pain, and sensorineural hearing loss bilateral. Review quarterly Minimum Data Set (MDS) for Resident #19 dated 03/31/21 revealed the resident was cognitively intact and was total dependent with activities of daily living, (ADL) with two persons for physical assist. Resident #19 has impairment on left side of body and uses a mobilized wheelchair. No refusal of care. Review of the plan of care dated 01/04/21 revealed Resident #19 has an ADL self-care performance deficit resulted to dementia, musculoskeletal impairment, and pain. Interventions included extensive assistance for bathing, allow time for task completion and allow sufficient time for dressing and undressing. Observation on 08/23/21 at 2:35 P.M., revealed #19 was lying in bed in a hospital gown and food particles in his beard. Interview on 08/23/21 at 2:40 P.M., revealed State Tested Nursing Aide (STNA) #70 verified findings. Interview on 08/24/21 at 10:43 A.M., revealed Resident #19 was lying in bed with hospital gown and distressed hair. Hair was oily. Resident reported he has not had a shower in a long time since he has been moved to another room. Resident #19 reported his hair has not been washed in weeks and it was oily. 2. Review of the medical record revealed Resident #216 was admitted on [DATE]. Diagnoses included but not limited to anxiety, hyperlipidemia, anemia, coronary artery disease, gastrointestinal, and arthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/07/21, revealed the resident had moderately impaired cognition for decision making and required supervision for bathing. No documentation indicating refusal of care. Review of the plan of care dated 02/01/21 ADL self-care performance deficit resulted to dementia, musculoskeletal impairment, and pain. Interventions included extensive assistance for bathing, allow time for task completion and allow sufficient time for dressing and undressing. Interview on 08/23/21 at 1:10 P.M., revealed Resident #216 reported she is supposed to receive showers three times a week on Tuesdays, Thursdays, and Saturdays during the day shift. Resident #216 reported she is not receiving showers as scheduled which makes things frustrating. Resident #216 stated she has been washing up in the sink but is unable to wash hair. Interview on 08/24/21 at 9:30 A.M., revealed Director of Nursing (DON) was unaware of residents not receiving showers as scheduled. DON reported residents should be offered showers upon their schedule and have the right to refuse care. DON verified Residents (#19 and #216) did not refuse care for showers. Review of the shower sheets dated August 2021 revealed the Residents (#19 and #216) had not received showers on 08/02/21, 08/06/21, 08/09/ 21, 08/11/21, 08/13/21, 08/16/21, 08/23/21, and 08/25/21. Residents were scheduled for showers three times a week every week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 6 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review policy titled, Personal Bathing and Showers, dated 05/30/19 revealed residents have the right to choose their schedules, consistent with their interests, assessments, and care plans including choice for personal hygiene. Review policy titled, Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility is to promote resident centered care by attending to the physical emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine care for the resident for hygienic purposes and for the psychosocial well-being of the resident including but not limited to hair hygiene that includes combing, brushing, shampoo, trimming and simple haircuts. Event ID: Facility ID: 365734 If continuation sheet Page 7 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 Based on record review, observation, interview and policy review, the facility failed to assess and report fingernail abnormality. This affected one (Resident #28) of three residents reviewed for nail care. The facility census was 74. Residents Affected - Few Findings include: Review of medical record for Resident #28 revealed an admission date on 09/04/20 with diagnoses including history of Covid-19, dementia with behaviors, hypertension, major depressive disorder, urinary tract infection, moderate protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/21, revealed the resident had a severely impaired cognition. Review of the plan of care for Resident #28 dated 04/30/21 revealed the resident has an activities of daily living (ADL) self care performance deficit related to dementia. Interventions include resident requires extensive assist for bathing, bed mobility, dressing and assist with personal hygiene and monitor document report as needed an changes, or reasons for self care deficit, expected course and decline in functioning. Review of the weekly skin checks dated 07/24/21 and 07/30/21 contained no documentation related to the resident's nails. Review of the podiatrist note dated 08/17/21 revealed the resident was treated at the bedside. Her toenails were trimmed without incident. Physical exam completed by the physician revealed resident had bilateral fungal nail infections, no open lesions were observed. Follow up appointment was scheduled in nine to ten weeks. Review of the nursing note dated 07/03/21 through 08/26/21 revealed no documentation of any abnormality of her finger nails. During observation on 08/25/21 at 7:00 A.M. Resident #28's finger nails on both hands were discolored, thickened and crumbling at the edges. One nail was lifting from the nail bed with surrounding redness. During interview on 08/25/21 at 7:25 A.M., Licensed Practical Nurse (LPN) #50 stated she did not know if the physician had addressed her fingernails. She stated there was no treatment in place for her finger nails at this time. During interview on 08/26/21 at 6:10 P.M., Corporate Nurse #79 stated she was unable to find any documents related to an assessment, treatment or notification to the physician of the resident's finger nails. Review of the facility policy titled Nail and Hair Hygiene Services, dated 04/04/17, revealed the nails will have routine nail hygiene as part of a bath or shower. Red or swollen nail beds will be reported to the nurse. This deficiency substantiates Complaint Number OH00125078. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 8 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, observation, interview and policy review, the facility failed to ensure cleaning chemicals were stored in a locked area on the memory care unit and failed to ensure window locks on the memory care unit on the second floor were operational to prevent the windows being completely opened. This had the potential to affect 20 confused and independently ambulatory residents ( Residents #3, #7, #10, #12, #14, #16, #17, #23, #31, #34, #35, #39, #41, #44, #45, #55, #61, #64, #116 and #166 ) identified by the facility. The facility census was 74. Findings include: 1. During observation on 08/23/21 at 12:00 P.M. of biohazard room in the women's secured memory care unit was unlocked. The room contained four full red sharp containers on a countertop. One box identified as biohazard material was partially full of red biohazard bags. Under the counter was a full spray bottle of disinfectant with warning label to keep out of reach of children. During observation on 08/23/21 at 12:04 P.M., the housekeeping closet door was unlocked with a gallon bottle of germicidal ultra-bleach on a shelf. The housekeeping cart inside the closet contained two bottles of disinfectant. There was a floor sink with hot and cold water faucets that had connecting hoses attached to two large gallon size buckets containing peroxide multiple surface cleaner. The label on the attached bottles of disinfectant bowel cleaner had warning labels to keep out of reach of children. During observation on 08/23/21 at 12:08 P.M., State Tested Nursing Assistant (STNA) #70 used a code to open the biohazard storage door. During interview on 08/23/21 at 12:09 P.M., STNA #70 stated she was unaware of the door being unlocked as she used the code on the electronic push button keypad to open door. She verified the door was unlocked and should automatically lock when closed. During observation of the biohazard room and housekeeping closet on 08/23/21 from 12:00 P.M. to 12:32 P.M., Residents #55, #10 and #12 ambulated past unlocked rooms without facility staff monitoring for safety until door locks were repaired. During interview on 08/23/21 at 12:50 P.M., Housekeeping and Laundry Supervisor stated the locks were not operational and he needed to have maintenance replace the batteries. 2. During observation on 08/23/21 12:37 P.M., the nursing station on the memory care unit revealed an unsecured bottle of chemical cleaner that was approximately one third full sitting on the back counter of the nursing station. The location was open and accessible to ambulatory residents. LPN #1 00 walked away from the nursing station and entered the dining room, leaving the leaving bottle of chemical unattended. The label on the bottle identified the solution as didecyl dimethyl ammonium chloride with a warning label to keep out of reach of children. The chemical is corrosive and causes irreversible eye damage and skin burns. During interview on 08/23/21 at 12:42 P.M., LPN #73 verified the chemical should be locked up at all times (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 9 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 - Some Review of facility policy titled Hazardous Materials Storage, dated 01/25/19, revealed the when hazardous chemicals are not in immediate use they are to be locked up. Chemicals on the nursing unit will be locked and stored when not in use. 3. Medical record review for Resident #35 revealed an admission date on 04/30/21. Review of the plan of care for Resident #35 dated 08/04/21 revealed resident wanders aimlessly from place to place and into other resident rooms. Interventions included complete wandering evaluation on admission readmission and quarterly, evaluate the need for a secured unit, notify staff of wandering risk, provide structured activities and diversionary tactics as needed. During observation on 08/26/21 at 11:30 A.M., Resident #35 had opened her window fully in her room on the second floor of the facility's locked memory care unit. She returned to her bed laying down and closing her eyes. Interview with Resident #35 on 08/26/21 at 11:32 A.M. stated she liked having her window open because it was cold in her room. The room temperature was 76 degrees Fahrenheit (F) on wall thermostat. During interview on 08/26/21 at 11:42 A.M., the Director of Nursing (DON) stated the windows should not open all the way and should only open a few inches. During observation on 08/26/21 at 11:59 A.M. to 12:29 P.M., all windows on the second floor in the women's and men's locked memory care unit were checked for the ability to open fully. Windows in rooms #217, #215, #207, #205 and #203 on the men's unit fully opened and did not have a screen. Windows in rooms #245, #251, #253, and #254 on the women's unit fully opened During interview on 08/26/21 at 1:00 P.M. with Corporate Nurse #79, Administrator, Director of Nursing, and Maintenance Staff #44 were notified the windows fully opened on the women's and men's locked unit. Maintenance Staff #44 stated locks were placed on all the windows approximately four months ago and he was unaware of any malfunctions. Review of the incident and accident log for 07/01/21 through 08/26/21 revealed no injuries related to the ability to fully open windows on the second floor of the facility. Interview on 08/26/21 at 3:30 P.M. with Regional Maintenance Director #80 verified stated the current locking mechanism were able to be moved if the window was forced open as they were not screwed into the window frame itself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 10 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review, observation and interview, the facility failed to employ a full time Director of Nursing (DON). This had the potential to affect all residents residing in the facility. The facility census was 66. Review of the facility staffing schedules for 08/16/21 through 08/23/21 revealed the DON was scheduled Monday through Friday. Observations from 08/23/21 through 08/26/21 at random intervals revealed the DON was across the street at the facility's sister facility. The DON would come back and forth as needed. Interview with the DON on 08/25/21 at 11:20 am revealed she was the DON for this facility and the facility next door. She verified she was the only DON working at both facilities. She stated she worked approximately 50 hours per week, 20 hours in the facility next door and 30 hours in the other facility. She stated she was sometimes working on things for this facility while in the other one but was not physically here. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 11 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 record review, interview, observation and policy review, the facility failed to adequately monitor medications for adverse side effects or identify the behaviors targeted for treatment. This affected two (Residents #59 and #168) of four residents reviewed for psychoactive medications. The facility census was 66. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including history of Covid-19, Alzheimer's disease, altered mental status, major depressive disorder, heart failure, kidney failure, falls, and delusional disorders. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/04/21, revealed the resident was cognitively impaired. The resident received an antipsychotic and an antidepressant daily during the assessment period. Review of the plan of care for Resident #59 dated 03/28/19 revealed resident has the potential for side effects of psychotropic medication usage. Interventions include administer medications as ordered and monitor for side effects and effectiveness every shift. Review of active physician orders for Resident #59 revealed an order dated 07/22/21 for Risperdal tablet 0.5 milligrams one time a day for delusions, Zyprexa 3.75 mg by mouth daily at bedtime for delusions dated 07/22/21 and Celexa 20 mg by mouth daily for the treatment of depression. Review of the medication administration record for Resident #59 for July 2021 and August 2021 contained no documentation of any medication side effect monitoring. Review of nursing progress notes dated 07/01/21 through 08/26/21 revealed no documentation related to medication monitoring for adverse side effects related to antidepressants and antipsychotic medications. During interview on 08/25/21 at 10:17 A.M., Licensed Practical Nurse (LPN) #73 stated she does not document any monitoring for adverse side effects for medication. 2. Record review revealed Resident #168 was admitted on [DATE] with diagnoses including atrial fibrillation, Alzheimer's disease, major depressive disorder, insomnia, psychosis and dementia. Review of the admission MDS assessment revealed the resident was cognitively impaired. The resident received an antipsychotic and antidepressant medication daily during the assessment period. Review of plan of care for Resident #168 revealed it was in progress. Review of nursing progress notes dated 08/01/21 through 08/26/21 contained no documentation of medication monitoring for adverse side effects related to antidepressants and antipsychotic medications. Review of the active physician orders for Resident #168 revealed an order dated 08/13/21 for Zyprexa 2.5 mg give one tablet two times a day for treatment of psychosis and Celexa 10 mg tablet give one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 12 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 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 tablet by mouth daily for the treatment of depression. Level of Harm - Minimal harm or potential for actual harm Review of the medication administration record for Resident #168 for the month of August 2021 revealed no documentation of medication side effect monitoring. Residents Affected - Few During interview on 08/25/21 at 8:35 A.M., LPN #70 revealed there used to be a place on the treatment administration record but there is no where to document that now. During interview on 08/26/21 at 4:25 P.M., Corporate Nurse #79 stated the facility has not been monitoring medication side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 13 of 14 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 365734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chamberlin Healthcare Center 3889 East Galbraith Road Cincinnati, OH 45236 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and policy review, the facility failed to ensure expired medications were disposed of timely. This had the potential to affect 41 residents residing on the Buckeye Lane and Tower Two units. The facility census was 74. Findings include: Observation on 08/26/21 at 10:10 A.M. of the Buckeye unit medication storage room revealed an opened and undated multi use vial of tuberculin purified protein with and expiration date of 02/22. Interview with Director of Nursing at the time of the observation verified the vial should have been dated when it was opened. Observation on 08/26/21 at 10:30 A.M. of Tower Two medication storage room revealed a bottle of vitamin D 1000 units opened with an expiration date of 03/2021, a opened bottle of oyster shell calcium 500 mg with an expiration date of 08/2020, an opened bottle of stool softener 100 mg with an expiration date of 01/2021, a plastic bag with promethazine rectal suppositories with an expiration date of 01/21, and eleven individual vials of prefilled influenza vaccines single dose with an expiration date of 03/21. Interview with the Director of Nursing at the time of the observation verified the expired medication should have been disposed of. Review of facility policy titled Medication Storage, dated 04/07/17, revealed expired medication will be disposed of in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 14 of 14