Health inspection·July 25, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cerebrovascular accident and returned to the facility on [DATE]. Resident #114 also discharged to the hospital on [DATE] with anemia and returned to the facility on [DATE]. Further review of Resident #114's chart revealed no evidence of Ombudsman notification for resident's hospitalizations on 02/26/19 and 03/29/19 were located in the chart. Interview with Business Office Coordinator #76 on 07/24/19 at 12:39 P.M. verified there was no evidence of the Ombudsman being notified of Resident #114's discharges to the hospital on [DATE] and 03/29/19. Review of the facility Resident Transfer and Discharge Rights from the Facility policy dated November 2016 revealed the facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman by certified mail or electric email. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365772 If continuation sheet Page 2 of 4 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 365772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastgate Health Care Center 4400 Glen Este Withamsville Road Cincinnati, OH 45245 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, observation, staff interview, and policy review, the facility failed to ensure a nurse provided the correct pressure ulcer dressing for a resident in accordance with a physician order. This affected one (#84) out of four residents reviewed for pressure wounds. The facility census was 167. Residents Affected - Few Findings include: Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include degeneration of brain, gastrointestinal hemorrhage, dysphagia, hyperlipidemia, electrolyte/fluid balance disorders, diabetes, chronic kidney disease, vitamin D, peripheral vascular disease, anxiety, hypertension, hypokalemia, transient ischemic attack, hemiplegia, anxiety, chronic obstructive pulmonary disease, osteoporosis, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 has severe cognitive deficits, and requires extensive assist to total dependence for activities of daily living, is frequently incontinent of bladder, and always incontinent of bowel. Review of care plan latest revision date of 08/07/18 revealed Resident #84 has the potential for skin impairment related to impaired mobility, incontinence, diabetes, history of skin breakdown, hemiplegia, and peripheral vascular disease. Continued review of care plan with latest revision date of 07/22/19 revealed Resident #84 has has a pressure ulcer to sacrum related to impaired mobility, incontinence, diabetes, fragile scar tissue related to history of pressure ulcer to sacrum, cerebral vascular accident, hemiparesis, peripheral vascular disease, hypertensive chronic kidney disease, dementia, and unaware of needs. Resident #84 has wound healing compromised by terminal prognosis, receiving hospice services. Reviewed of wound care note dated 01/23/17 revealed the sacrum wound was acquired on 11/13/16 and healed on 01/23/17. Further review of wound care notes dated 03/05/19 revealed the old wound opened again and healed and reopened again on 03/05/19 and is in the process of healing at this time measuring 0.3 centimeters (cm) long by 0.1 cm wide by 0.2 cm in depth on 07/22/19. Review of physician order dated 07/12/19 revealed to cleanse sacral wound with normal saline and pat dry. Apply max-absorb extra AG wound dressing and cover with gauze pad four inches by four inches and secure with tape. Change daily and as needed. Observation on 07/24/19 from 2:30 P.M. to 3:00 P.M. with two Registered Nurses (RN) #52 and #173 providing wound care to Resident #84. During the observation, RN #52 removed the old dressing, removed his/her soiled gloves, washed his/her hands, donned new gloves, changed his/her gloves and measured the wound. RN #52 then removed his/her soiled gloves, washed his/her hands, donned new gloves, cleansed wound with normal saline, removed his/her soiled gloves, washed his/her hands and donned new gloves. RN #52 then applied max-absorb to the wound on the sacral area, then placed the tape on the dressing and did not place a gauze pad four inches by four inches prior to securing with tape. Interview on 07/24/19 at 2:54 P.M. during observation RN #52 verified she did not place the gauze pad four inches by four inches over the max-absorb prior to securing with tape and stated he/she would redo the dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365772 If continuation sheet Page 3 of 4 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 365772 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eastgate Health Care Center 4400 Glen Este Withamsville Road Cincinnati, OH 45245 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 0686 Review of the Infection Control-Dressings, Dry/Clean Policy dated 04/2017 revealed to apply the ordered treatment, dressing, and secure with tape. 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: 365772 If continuation sheet Page 4 of 4