Inspection·October 26, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the physical abuse allegation involving Resident #115 hitting Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by State Tested Nursing Assistant (STNA) #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as Activities Leader (AL) #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by AL #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors, the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Interview with Regional Clinical Director (RCD) (#503) on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility continued to investigate. RCD #503 stated the incident happened at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 2 of 11 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 10/26/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the end of AL #215's shift on 09/22/23 and she left the building was not scheduled to return until the following Tuesday (09/26/23). RCD #503 indicated AL #215 was suspended on 09/25/23 pending the outcome of the investigation. RCD #503 stated AL #215 denied the incident of encouraging Resident #115 to get Resident #108; however, the facility felt with the witness statements of the other staff members verifying the incident, they had to err on the side of caution related to the resident's safety and terminated AL #215 effective on 10/17/23. Interview with the STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the AL #215's personnel file revealed she was hired on 05/31/23 and terminated from the employment at the facility on 10/17/23. AL #215's employee file contained a disciplinary action dated 09/29/23 which indicated a reason for termination, flagrant poor performance indicating an irresponsible lack of knowledge or decision-making process, resulting in measurable loss to the company, whether monetary, in customer confidence or in employee relation issues. AL #215 was terminated following an incident involving residents on the memory care unit. Notes indicated there was an altercation between Resident #115 and Resident #108 and MHC #600 and STNA #239 broke it up. AL #215 was talking with Resident #115 and taping her on the shoulder which is a trigger to Resident #115's behaviors. AL #215 was egging her on and Resident #115 hit another resident (Resident #100). AL #215 was reported as not calming Resident #115 down but instead agitating Resident #115 further which triggered the second incident (Resident #115 striking Resident #100). AL #215 denied the incident and noted she was familiar with Resident #115 since she worked with the resident at another facility. Notes indicated MHC #600 and STNA #239 reported AL #215 further agitated Resident #115. Notes indicated the DON signed the termination letter on 09/29/23 and it was approved by the Human Resources office effective 10/17/23. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent to ensure the facility was to prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 3 of 11 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 10/26/2023 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 0600 Level of Harm - Minimal harm or potential for actual harm immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint number OH00146998. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 4 of 11 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 10/26/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility Self-Reported Incidents (SRIs) staff interviews, review of witness statements, review of employee personnel file, and review of facility policy, the facility failed to ensure the facility's abuse policy was implemented when two separate incidents of resident-to-resident physical abuse occurred. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Residents Affected - Few Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the dining room with her walker when Resident #115 grabbed her. Resident #108 then pushed Resident #115 which resulted in Resident #115 getting a scratch wound on her face. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly MDS assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved in the resident-to-resident physical abuse from Resident #115 recorded on 09/22/23. Review of the medical record for Resident #115 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA), cerebral infarction (stroke), dementia, psychotic disturbance, mood disturbance, anxiety, essential primary hypertension, major depressive disorder, asthma, dysphagia, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] for Resident #115, revealed the resident was severely cognitively impaired. Further review of the MDS assessment revealed the resident required assistance from staff with bed mobility, transfers and required supervision from staff with walking. Review of the plan of care revised on 09/15/23 for Resident #115 revealed the resident had behavior problems and had resident-to-resident altercations. Interventions included intervening as necessary to protect the rights and safety of others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 5 of 11 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 10/26/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse's progress notes for Resident #115 dated 09/22/23 at 3:31 P.M. authored by Registered Nurse (RN) #188 revealed the resident had a scratch wound on her face (from an altercation with Resident #108). Resident #115 was assessed and found to be in no distress and in no pain. The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the resident-to-resident physical abuse involving Resident #115 hitting Resident #100. Review of a witness statement by State Tested Nursing Assistant (STNA) #239 dated 09/22/23 revealed as she came down the hallway one resident (#108) was trying to enter the dining room when she passed another resident (#115) and Resident #115 expressed anger and grabbed onto Resident #108's clothing. Resident #108 pushed Resident #115 resulting in scratches down Resident #115's face. Review of a witness statement by Resident #108 dated 09/22/23 and collected by STNA #239 revealed the resident was walking into the dining room and Resident #115 blocked her way. As Resident #108 went to back up, Resident #115 grabbed her by her gown. Resident #108 was trying to get out her grip and pushed Resident #115. Review of a witness statement authored by Activities Leader (AL) #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by STNA #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as AL #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors; the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 6 of 11 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 10/26/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Residents Affected - Few Interview with Regional Clinical Director (RCD) #503 on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility investigated the allegations. RCD #503 verified their abuse policy was not implemented when two separate resident-to-resident physical abuse allegations occurred because the administration at the facility was not aware of the incidents until 09/25/23. RCD #503 stated the incident happened at the end of AL #215's shift on 09/22/23 and she left the building was not scheduled to return until the following Tuesday (09/26/23). RCD #503 indicated AL #215 was suspended on 09/25/23 pending the outcome of the investigation. RCD #503 stated AL #215 denied the incident of encouraging Resident #115 to get Resident #108; however, the facility felt with the witness statements of the other staff members verifying the incident, they had to err on the side of caution related to the resident's safety and terminated AL #215 effective on 10/17/23. Interview with STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent of the facility to ensure the facility would prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 7 of 11 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 10/26/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. This deficiency represents non-compliance investigated under Complaint number OH00146998. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 8 of 11 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 10/26/2023 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 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 record review, staff interviews, review of facility's self-reported incidents (SRIs), review of witness statements, and review of facility policy review, the facility failed to timely report allegations of resident-to-resident physical abuse to the state agency. This affected three (#108, #100 and #115) out of three residents reviewed for abuse. The facility census was 137. Findings include: Review of the medical record for Resident #108 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Dementia, osteoarthritis, alcohol dependence, essential primary hypertension. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #108 dated 09/13/23, revealed the resident had mild cognitive impairment. Resident #108 required extensive assistance from staff with bed mobility and transfers. Review of the nurse's progress notes for Resident #108 dated 09/22/23, revealed the resident was going toward the dining room with her walker when Resident #115 grabbed her. Resident #108 then pushed Resident #115 which resulted in Resident #115 getting a scratch wound on her face. Review of the medical record for Resident #100 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, cocaine dependence, constipation, psychoactive substance abuse, pseudobulbar affect, anoxic brain damage, impulsiveness, ataxia, and cognitive communication deficit. Review of the quarterly MDS assessment 3.0 dated 07/14/23 for Resident #100 revealed the resident had severely impaired cognition. Resident #100 required extensive assistance from staff with transfers. Review of the September 2023 nursing notes for Resident #100 revealed no documentation regarding the resident being involved in the resident-to-resident physical abuse allegation from Resident #115 recorded on 09/22/23. Review of the medical record for Resident #115 revealed the resident was admitted to the facility on [DATE]. Diagnoses included transient ischemic attack (TIA), cerebral infarction (stroke), dementia, psychotic disturbance, mood disturbance, anxiety, essential primary hypertension, major depressive disorder, asthma, dysphagia, and hemiplegia and hemiparesis. Review of the quarterly MDS assessment dated [DATE] for Resident #115, revealed the resident was severely cognitively impaired. Further review of the MDS assessment revealed the resident required assistance from staff with bed mobility, transfers and required supervision from staff with walking. Review of the plan of care revised on 09/15/23 for Resident #115 revealed the resident had behavior problems and had resident to resident altercations. Interventions included intervening as necessary to protect the rights and safety of others. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 9 of 11 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 10/26/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse's progress notes for Resident #115 dated 09/22/23 at 3:31 P.M. and authored by Registered Nurse (RN) #188 revealed the resident had a scratch wound on her face (from an altercation with Resident #108). Resident #115 was assessed and found to be in no distress and in no pain. The nurse provided wound care to the scratch and the Assistant Director of Nursing (ADON), and the Nurse Practitioner were notified. The progress notes revealed no documentation regarding the resident-to-resident physical abuse allegation involving Resident #115 hitting Resident #100. Review of a witness statement by State Tested Nursing Assistant (STNA) #239 dated 09/22/23 revealed as she came down the hallway one resident (#108) was trying to enter the dining room when she passed another resident (#115) and Resident #115 expressed anger and grabbed onto Resident #108's clothing. Resident #108 pushed Resident #115 resulting in scratches down Resident #115's face. Review of a witness statement by Resident #108 dated 09/22/23 and collected by STNA #239 revealed the resident was walking into the dining room and Resident #115 blocked her way. As Resident #108 went to back up, Resident #115 grabbed her by her gown. Resident #108 was trying to get out her grip and pushed Resident #115. Review of a witness statement authored by Activities Leader (AL) #215 dated 09/22/23, revealed Resident #115 hit another resident (Resident #108) and Mental Health Counselor (MHC) #600 broke it up. AL #215 asked Resident #115 to stop being a bully and when she touched the resident's hand, Resident #115 hit Resident #100. Review of a witness statement by Resident #100 dated 09/22/23 and collected by STNA #239, revealed the resident was sitting by the dining room when two other residents (#115 and #108) were fighting. One resident (#115) was still mad after the incident and a woman (identified as AL #215) told the resident to get her and that resident hit Resident #100 on her left arm. Review of a witness statement authored by RN #188 dated 09/22/23, revealed a staff member was provoking Resident #115 saying go get her but Resident #115 turned and hit Resident #100. Review of the facility's SRI tracking number 239557, created on 09/25/23 at 11:34 A.M., revealed an allegation of physical abuse was discovered on 09/22/23. Notes revealed Resident #108 was walking into the dining room when Resident # 115 grabbed Resident #108's clothing and pushed her. Resident #108 defended herself and inflicted scratches on Resident #115's face. The residents were immediately separated and both residents were assessed for injury. The Administrator, the Director of Nursing (DON), the physician, and the sponsor were notified. The SRI was closed on 09/29/23 at 2:48 P.M. and was unsubstantiated due to inconclusive evidence. Review of the facility's SRI tracking number 239560, created on 09/25/23 at 12:14 P.M., revealed an allegation of physical abuse was discovered on 09/22/23 at 12:55 P.M. The SRI indicated Resident #115 struck Resident #100 directly after Resident #115 had struck Resident #108. Notes indicated the resident's sponsors; the physician and the police were immediately notified. The investigation revealed an employee (MHC #600) overheard another employee (AL #215) telling Resident #115 to get her as in referring to Resident #115 getting Resident #108. Notes indicated Resident #115 then hit Resident #100. AL #215 was suspended pending an investigation. The SRI was closed on 09/29/23 at 12:07 P.M. and was unsubstantiated due to inconclusive evidence. Review of the witness statement from MHC #600 dated 09/25/23, revealed he was on the memory care unit when he observed Resident #115 walk past him and push Resident #108. MHC #600 stated he separated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 10 of 11 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 10/26/2023 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 0609 Level of Harm - Minimal harm or potential for actual harm Resident #115 from Resident #108 with the assistance of STNA #239. MHC #600 stated after they separated the two Residents, he observed AL #215 continue to agitate Resident #115 by tapping Resident #115's arm and stating to Resident #115, go get her. MHC #600 observed AL #215 begin to play fight with Resident #115 which appeared to agitate Resident #115 even more. MHC #600 reported Resident #115 turned and hit Resident #100 until MHC #600 separated Resident #115 from Resident #100. Residents Affected - Few Interview with Regional Clinical Director (RCD) (#503) on 10/19/23 at 12:44 P.M., indicated she came into the facility for the morning meeting on 09/25/23 and while she was reviewing progress notes, she discovered the incident between Resident #115 and Resident #108 on 09/22/23. While reviewing the incident between #115 and #108, she learned of the incident involving Resident #115 and Resident #100 on 09/22/23. RCD #503 indicated the former Administrator opened two different SRIs (239557 and 239560) on 09/25/23 as the facility investigated the allegations. RCD #503 verified the two separate resident-to-resident physical abuse allegations were not timely reported to the state agency because the administration at the facility was not aware of the incidents until 09/25/23. Interview with STNA #239 on 10/26/23 at 9:19 A.M., revealed she approached the dining room when she observed Resident #115 hit Resident #108. STNA #239 stated it happened so fast that it was hard to tell what exactly happened. STNA #239 indicated she heard AL #215 say to Resident #115, go get her. STNA #239 stated Resident #115 then hit Resident #100. Interview with MHC #600 on 10/26/23 at 10:49 A.M., revealed he was standing in the hallway when he observed an altercation between Resident #115 and Resident #108. MHC #600 stated he was able to get the two residents separated and when he was trying to calm the two residents down, he observed AL #215 continue to agitate Resident #115 by encouraging her to get her (meaning Resident #108) and AL #215 was poking Resident #115's shoulder. MHC #600 stated AL #215 continued to agitate Resident #115, when Resident then hit Resident #100. MHC #600 stated he wrote a statement about his observations and gave it to the Human Resource Manager. MHC #600 stated he also spoke with the Regional Operations Manager (ROM) #505 regarding this incident. Interview with RN #188 on 10/26/23 at 4:31 P.M. indicated he was the nurse working on 09/22/23 and did not see any of the incident between Residents #115 and #108 or the incident between Residents #115 and #100. RN #188 stated he was told Resident #115 grabbed Resident #108 as she was walking in the dining room and Resident #108 reacted to the this and Resident #115 had scratches down both sides of her face. RN #188 stated he was told AL #215 encouraged Resident #115 to go get her meaning go after Resident #108. RN #188 stated Resident #115 was agitated and hit Resident #100. RN #188 indicated Resident #100 had no injuries. Review of the undated facility policy titled, Ohio Abuse, Neglect, & Misappropriation, stated the it is the intent of the facility to ensure the facility would prevent abuse, mistreatment, or neglect of residents. The policy revealed any allegation of abuse must be reported immediately to the Executive Director and to the state agency. The facility would take measures to protect residents from harm by immediately initiating an investigation. In the event a situation is identified as abuse, an investigation by the executive leadership will immediately begin. An employee who is alleged or accused of being a party to abuse will immediately be interviewed by the staff nurse, escorted off the premises by another staff member, interviewed by facility leadership for a written statement and not left alone. Documentation of the facts and findings will be completed in each resident medical record. This deficiency represents non-compliance investigated under Complaint number OH00146998. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365734 If continuation sheet Page 11 of 11