Inspection·May 9, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, observations and resident, family and staff interviews, the facility failed to implement the resident's comprehensive care plans. This affected three (#12, #21, and #88) of 19 residents reviewed for care plans. The facility census was 38. Findings include: 1. Review of medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 04/09/19, revealed Resident #12 was cognitively intact. Review of the care plan, dated 05/03/19, revealed to check the shunt site (implanted tube to which an artery and vein in your arm is attached and provides larger than normal volume of blood flow for effective hemodialysis) every shift and to notify the physician of absence of thrill or bruit. Review of the Treatment Administration Record (TAR) for 05/2019 revealed no documentation that the shunt site was checked every shift or refused by the resident from 05/03/19 through 05/09/19. Review of the nurse's note from 05/03/19 to 05/08/19 revealed there were no entries the treatment was performed, held or refused by resident during this time. Interview on 05/08/19 at 10:34 A.M. with Resident #12 reported the facility does not check the shunt every shift. Interview on 05/08/19 at 11:00 A.M. with Licensed Practical Nurse (LPN) # 37 reported Resident #12 was non-compliant with treatment. LPN #37 verified there was no documentation in the records that stated noncompliance. LPN #37 verified there were no initials on the TARS for checking the resident's shut site. 2. Review of medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, pneumonitis due to inhalation of food and vomit, cognitive communication deficit and dementia. Review of the quarterly MDS assessment, dated 02/16/19, revealed Resident #21 was moderately impaired cognitive status and was totally dependent on staff for personal care. Review of the care plan, dated 07/24/18, revealed Resident #21 has oral/dental health problems and provide mouth care as per Activity of Daily Living (ADL) personal hygiene. Review of Resident #21's ADL oral care sheet revealed it stated to provide oral care as needed. The ADL oral care sheet showed Resident #21 had not received any oral care for the past 14 days. Interview on 05/07/19 at 8:57 A.M. with Resident #21's family member reported the facility does not brush Resident #21's teeth on a regular basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 2 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observations on 05/08/19 at 10:35 A.M. and on 05/09/19 at 10:58 A.M., revealed a foul smell coming from Resident #21's mouth. Observation of the resident's room revealed there were no toothbrush or tooth swabs in his room. Interview on 05/09/19 at 11:07 A.M. with State Tested Nursing Assistant (STNA) #75 reported she was not aware of performing dental care to Resident #21 because it was not on the ADL sheet. Interview with Licensed Practical Nurse (LPN) #38 on 05/09/19 at 12:25 P.M. verified Resident #21's ADL sheet for oral care had him scheduled to be checked for dental care on an as needed basis instead of being scheduled on a routinely basis. LPN #38 changed Resident #21's oral care to be performed on a routine basis for every day and every night. 3. Review of medical records revealed Resident #88's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral, muscle weakness, abnormalities of gait and mobility and chronic atrial fibrillation. Review of the care plan, dated 05/07/19, revealed Resident #88 was to wear [NAME] hose during the day and off in the evening. Review of the nurse's note from 05/03/19 to 05/08/19 revealed no entries discussing the resident refused to wear [NAME] hose. Observation on 05/07/19 at 11:45 A.M., revealed Resident #88's feet were not positioned on the leg rest in wheelchair. Resident #58 did not have any [NAME] hose on and her legs were red and swollen. The resident reported the swelling to STNA #58. STNA #58 verified Resident #88 did not have any [NAME] hose on her feet at this time. Observation on 05/08/19 at 5:08 P.M. of Resident #88 revealed the resident was sitting in the dining room eating her meal. Resident #88 did not have any [NAME] hose on her feet. STNA #62 confirmed at this time the resident did not have [NAME] hose on her feet. Interview on 05/08/19 at 6:08 P.M., revealed LPN #37 reported resident has been refusing to put on [NAME] hose. LPN #27 verified there were no progress notes that stated she refused to wear them. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 3 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, staff interview, observation, and review of facility policy, the facility failed to ensure a resident who required assistance from staff received personal hygiene routinely. This affected one of one residents reviewed for dental hygiene. The facility identified all 39 residents required assistance with activities of daily living. Residents Affected - Few Findings include: Review of medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, pneumonitis due to inhalation of food and vomit, cognitive communication deficit and dementia. Review of the quarterly MDS assessment, dated 02/16/19, revealed Resident #21 was moderately impaired cognitive status and was totally dependent on staff for personal care. Review of the care plan, dated 07/24/18, revealed Resident #21 has oral/dental health problems and provide mouth care as per Activity of Daily Living (ADL) personal hygiene. Review of Resident #21's ADL oral care sheet revealed it stated to provide oral care as needed. The ADL oral care sheet showed Resident #21 had not received any oral care for the past 14 days. Interview on 05/07/19 at 8:57 A.M. with Resident #21's family member reported the facility does not brush Resident #21's teeth on a regular basis. Observations on 05/08/19 at 10:35 A.M. and on 05/09/19 at 10:58 A.M., revealed a foul smell coming from Resident #21's mouth. Observation of the resident's room revealed there were no toothbrush or tooth swabs in his room. Interview on 05/09/19 at 11:07 A.M. with State Tested Nursing Assistant (STNA) #75 reported she was not aware of performing dental care to Resident #21 because it was not on the ADL sheet. Interview with Licensed Practical Nurse (LPN) #38 on 05/09/19 at 12:25 P.M. verified Resident #21's ADL sheet for oral care had him scheduled to be checked for dental care on an as needed basis instead of being scheduled on a routinely basis. LPN #38 changed Resident #21's oral care to be performed on a routine basis for every day and every night. Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revealed residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 4 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to ensure a shunt site was checked every shift and the weights were obtained per physician orders for a resident receiving dialysis services. This affected one (#12) of one resident reviewed for dialysis. The facility identified one resident was receiving dialysis at the time of the survey. The facility census was 38. Residents Affected - Few Findings include: Review of medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with dependence on renal dialysis. Review of the Minimum Data Set (MDS) assessment, dated 04/09/19, revealed Resident #12 was cognitively intact. Review of the care plan, dated 05/03/19, revealed to check shunt site (implanted tube to which an artery and vein in your arm is attached and provides larger than normal volume of blood flow for effective hemodialysis) every shift and to notify the physician of absence of thrill or bruit. Review of the Treatment Administration Record (TAR) for 05/2019 revealed no documentation that the shunt site was checked every shift or refused by the resident from 05/03/19 through 05/09/19. Review of the nurse's note from 05/03/19 to 05/08/19 revealed there were no entries the treatment was performed, held or refused by resident during this time. Interview on 05/08/19 at 10:34 A.M. with Resident #12 reported the facility does not check the shunt every shift. Interview on 05/08/19 at 11:00 A.M. with Licensed Practical Nurse (LPN) # 37 reported Resident #12 was non-compliant with treatment. LPN #37 verified there was no documentation in the records that stated noncompliance. LPN #37 verified there were no initials on the TARS for checking the resident's shut site. Further review of physician orders, dated 05/03/19, revealed to obtain daily weights every night shift for monitoring. Review of the TAR for 05/2019 revealed no documentation that weights were takes or refused by the resident on 05/05/19, 05/06/19, 05/07/19, and 05/08/19. Review of nurse's notes form 05/05/19 to 05/08/19 revealed no entries the ordered weights were taken, held or refused by the resident on the above dates. Interview on 05/08/19 at 10:33 A.M. revealed Resident #12 reported the facility use to take her weights every day but stopped. Resident #12 denied she refused to be weighed. Interview on 05/08/19 at 1:18 PM with Licensed Practical Nurse (LPN) #37 revealed verified the physician order was for daily weights and verified the weights were not taken for four days, from 05/05/19 to 05/08/19. LPN #37 reported weights were scheduled for 6:00 A.M., which was third shift's responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 5 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to label, date, and discard expired food items from the walk-in refrigerator and freezer. The facility also failed to serve food in a sanitary environment. This had the potential to affect all 38 residents who receive food from the kitchen. Findings include: 1. On 05/06/19 from 6:15 P.M. to 6:35 P.M., an initial tour of the kitchen was conducted with Kitchen Manager (KM) #66. During the observation, the following concerns were observed, and all the concerns were verified by KM #66. a. In the refrigerator, there was a container of cut up cucumbers, a container of chopped boiled eggs, a container of cherry tomatoes and a container of shredded cheese sealed with no dates or used by dates. b. In the freezer, there were a plastic bag of mozzarella sticks, two plastic bags of french fries that were rewrapped, a bag of hash browns rewrapped in a clear plastic bag, two five-pounds of lamb rewrapped sealed in plastic covering and one five-pound turkey breast wrapped in aluminum foil with no dates or used by dates. c. The utensil bin was filled with crumbs, grease and unknown food particles scattered throughout the bin. d. The deep fryer was heavily covered with grease in the front, the top and on both sides. KM #66 reported the facility cleans the deep fryer weekly but was unable to provide the cleaning schedule. Reviewed policy titled Use By Dating Guideline, dated 09/09/11 revealed items in the refrigerator ready to eat potentially hazardous foods, including but not limited to: milk, yogurt, cottage cheese, cooked foods, hard cooked eggs and produce have a use by date of seven days and if foods are stored in the freezer that have been opened utilized a use by date of seven days once the item is opened. 2. Observation in the kitchen on 05/07/19 at 2:19 P.M. revealed Lead [NAME] (LC) #67 was in standing next to a baker's rack with two sheets of cake uncovered with a hairnet on top of her head leaving some of her hair hanging out. Interview on 05/07/19 at 2:25 P.M., revealed LC #67 reported she felt her hair on her neck but was not aware it was not in the hair net. 3. Observation of the resident's refrigerator on 05/07/19 at 4:04 P.M. revealed it had food items that were not labeled or discarded. The refrigerator door was titled Residents Food Only. In the refrigerator, there was a container of lasagna with a date of 04/06/19 and a 16 ounce (oz.) container of salsa with no date or used by date. In the bottom part of the refrigerator, there was an unidentifiable red liquid that spilled and dried up at the bottom of refrigerator underneath the vegetable bins. Interview on 05/07/19 at 4:22 P.M. revealed the activities department had a party for the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 6 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and placed the left overs in the refrigerators. The DON stated she was not sure who was responsible for cleaning it and discarding out dated food. Review policy titled Resident Personal Food Storage and Handling revealed all prepared or opened perishable food or beverages brought by the guest, family, or visitors for residents use will be labeled with the guest name and the date the item was stored. Resident food that is prepared and opened, will be kept for six days from label date and then discarded except: condiment-type foods will be kept for two months/60 days. Non perishable foods/frozen foods will be kept for one month. 4. Observation on 05/09/19 at 3:46 P.M., revealed Dining Servers (DS) #73, #74, #75, #76, and #77 were in the kitchen with no hair nets. Food was being prepared for dinner on 05/09/19 and breakfast for 05/10/19. There was apple cobbler left uncovered, cranberry crumb muffins left uncovered, coffee cake, dinner rolls and cooked chicken quarters uncovered. Interview with [NAME] #68 at 3:50 P.M., revealed staff knows that they need to wear their hair nets while food was being prepared or being cooked. [NAME] #68 verified the Dining Servers had no hair nets on. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 7 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0880 Provide and implement an infection prevention and control program. 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, staff interview, policy review, and review of the Center for Disease Control guidelines, the facility failed to implement appropriate infection control precautions. This affected one (#91) of four residents observed for medication administration, and two residents (#37 and #38) reviewed on the facility's infection control logs. The facility identified one resident who was on intravenous medication. This had the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: 1. Record review for Resident #91 revealed the resident was admitted to the facility on [DATE] with diagnoses including Methicillin resistant staphylococcus aureus (MRSA), bacteremia and clostridium difficile. Observation of medication administration on 05/08/19 at 9:00 A.M. with Registered Nurse (RN) #18 revealed that RN #18 flushed Residents #91's central line with heparin and did not clean the needless access tip with alcohol prior to administration. Interview on 05/08/19 at 9:02 A.M. with RN #18 verified she forgot to wipe the needless access tip of the central line prior to flushing with heparin. Review of the Administration of an Intermittent Infusion policy, dated 05/01/15, revealed to vigorously cleanse needleless connector with alcohol. Allow to air dry. 2. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with a re-entry on 01/25/19. Diagnoses included a right humerus fracture and a pelvic fracture. The resident was discharged from the facility on 02/19/19. Review of the Discharge-Return Not Anticipated Minimum Data Set (MDS) assessment, dated 02/19/19, revealed Resident #37 had severe cognitive deficits, required extensive assist with toileting and was always incontinent of bowel and bladder. Review of urinalysis and culture and sensitivity (UA & C/S) results, dated 02/08/19, revealed Resident #37 had a urinary tract infection with Klebsiella pneumoniae (a multi-resistant bacteria). Review of physician order's was silent for orders for contact isolation. 3. Record review for Resident #38 revealed the resident was admitted to the facility on [DATE] with a re-entry on 05/07/19. Diagnoses included respiratory failure and coronary artery disease. Review of the Discharge-Return Not Anticipated MDS assessment, dated 04/20/19, revealed Resident #38 had no cognitive deficits, required supervision with activities of daily living, was occasionally incontinent of bladder, and was continent of bowel. Review of the UA & C/S results, dated 04/01/19, revealed that Resident #38 had a urinary tract infection with Klebsiella pneumoniae (a multi-resistant bacteria). Review of physician order's was silent for orders for contact isolation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365798 If continuation sheet Page 8 of 9 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 365798 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard at Seasons 7100 Dearwester Drive 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 05/09/19 at 2:15 P.M. with RN #9 verified Resident #37 and #38 were not in contact precautions during her stay at the facility. Review of the Isolation-Categories of Transmission Based Precautions, dated 01/2012, revealed that in addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Event ID: Facility ID: 365798 If continuation sheet Page 9 of 9