Inspection·April 4, 2019

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 observation, record review, review of facility policy and staff interviews, the facility failed to ensure call lights were within reach of the residents. This affected three (#19, #30 and #90) of seventeen residents investigated in the final sample. The facility census was 64. Residents Affected - Few Findings include: 1. Review of Resident #19 medical record revealed an admission date of 04/28/18. Diagnoses included fracture of pelvis, repeated falls, dementia and osteoarthritis left knee. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively impaired and required extensive assist of one for all activities of daily living except supervision only for eating, no behaviors, and had no restraints or alarms. 2. Review of the medical record for Resident #30 revealed an admission date of 01/26/18. Diagnoses included schizoaffective disorder, psychosis, disorder of adult personality and behavior, insomnia, heart failure, chronic obstructive pulmonary disease, and convulsions. Review of a quarterly MDS assessment dated [DATE] revealed Resident #30 was cognitively intact and required extensive assist of two for transfers and extensive assist of one for all other activities of daily living. Review of a care plan, dated 11/16/17, listed a fall prevention intervention which included to keep the call light within the resident's reach and encourage/remind her to use. 3. Review of Resident #90's medical record revealed an admission date of 03/11/19. Diagnoses included cerebral infarction, diabetes, osteoporosis and atrial fibrillation. Review of a 14-day MDS assessment, dated 03/25/19, indicated Resident #90 was cognitively impaired and required extensive assist of one for all activities of daily living except total dependence for eating and toileting. Observation and interview on 04/01/19 from 9:20 A.M. to 9:30 A.M. with State Tested Nurse Assistant #89 reported Residents #19, #30 and #90 would activate their call lights for assistance and verified the call lights were out of reach for Residents #19, #30 and #90. Review of the facility policy Answering the Call Light, dated 10/2010, indicated to be sure the call light was within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 2 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, review of facility policy and staff interviews, the facility failed to notify a resident and/or resident representative of a resident's significant weight loss. This affected one (#34) of five residents reviewed for nutrition. The facility identified five residents who had significant weight loss or gain. The facility census was 64. Findings include: Review of Resident #34's medical recorded revealed an admission date of 08/14/18. Diagnoses included stricture of ureter obstructive uropathy, pneumonia, anemia, congestive heart failure, atrial fibrillation, gastroesophageal reflux disorder and dysphagia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 had cognitive impairment and had weight loss greater than 10 percent while not on a prescribed weight loss regimen. Review of Resident #34's weight record revealed weights on 10/27/18 of 159.9 pounds (lbs.), 12/02/18 was 157.8 lbs., 01/20/19 was 143.4 lbs., 02/05/19 was 144.0 lbs., 03/12/19 was 144 lbs. and 04/02/19 at 141 lbs. The weight log indicated a significant weight loss of 11.8% in six months. Review of a dietary note dated 02/01/19 indicated Resident #34 had a 11-pound weight loss in 30 days. The recommendation was for the high calorie nutritional supplement, named Med Pass, be increased from 120 to 240 milliliters (ml.) twice daily due to weight loss. It was noted the Nurse Practitioner was made aware of the significant weight loss. There was no evidence in the medical record the resident's daughter was made aware of the resident's weight loss. Phone interview with Resident #34's daughter on 04/01/19 at 3:12 P.M. reported she was unaware the resident had any weight loss. Interview on 04/02/19 at 11:38 A.M. with Unit Manager (UM) #10 reported dietary staff were to inform physician and family of the resident's weight loss. The UM verified Resident #34's power of attorney was his daughter. Interview on 04/02/19 at 2:59 P.M. with Dietician #122 and Diet Technician #121 stated they report weight losses to nursing during the weekly at risk meeting, but nursing was responsible for family and physician notification. Review of facility policy Nutritional Review, dated 10/07/09 revealed physician and staff will coordinate nutritional interventions with resident's surrogate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 3 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral vascular accident, bradycardia, failure to thrive and weakness. Review of the most recent quarterly MDS assessment, dated 01/11/19, identified Resident #17 as being moderately impaired in cognition. Review of the nursing progress notes revealed Resident #17 was hospitalized on [DATE] and returned to the facility on [DATE]. Review of the record for Resident #17 revealed the record was silent regarding written notification to the resident and/or resident's representative and the Office of the State Long-Term Care Ombudsman of resident's hospitalization on 02/20/19. Interview with the Administrator on 04/03/19 at 11:45 A.M. confirmed the facility did not provide written notification to the resident and/or resident's representative nor to the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for Residents #5, #17, and #20. 2. Review of Resident #20's medical record revealed an admit date of 10/17/18 with diagnoses including urinary tract infection, osteopathy, chronic obstructive pulmonary disease, dementia, anemia, repeated falls, heart failure, and hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively impaired. Review of a progress note revealed Resident #20 had a fall on 03/29/19 and was sent out to the hospital 9-1-1. Resident #20 returned to the facility 04/01/19 with diagnoses of acute cystitis, acute kidney injury, scalp laceration, and skin tears. Review of the record for Resident #20 revealed the record was silent regarding written notification to the resident and/or resident's representative and the Office of the State Long-Term Care Ombudsman of resident's hospitalization on 02/20/19. Based on record review and staff interview, the facility failed to notify the resident and/or resident's representative and the Office of the State Long-Term Care Ombudsman in writing upon the resident's transfer to the hospital. This affected three (Residents #5, #17 and #20) of three residents reviewed for hospitalization. The facility census was 64. Findings include: 1. Review of record revealed Resident #5 was admitted on [DATE] with diagnoses which included end stage renal disease. Review of the nursing progress notes, dated 02/20/19 through 02/23/19, revealed the facility was notified that the resident was sent to the hospital from the dialysis center on 02/20/19 for evaluation of a cough. The nursing progress notes revealed Resident #5 was admitted to the hospital on [DATE] with a diagnosis of respiratory infection. Review of the record for Resident #5 revealed the record was silent regarding written notification to the resident and/or resident's representative and the Office of the State Long-Term Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 4 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0623 Ombudsman of resident's hospitalization on 02/20/19. 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: 365812 If continuation sheet Page 5 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral vascular accident, bradycardia, failure to thrive and weakness. Review of the most recent quarterly MDS assessment, dated 01/11/19, identified Resident #17 as being moderately impaired in cognition. Review of the nursing progress notes revealed Resident #17 was hospitalized on [DATE] and returned to the facility on [DATE]. Review of the record for Resident #17 revealed the record was silent regarding written notification of the facility's bed hold policy to the resident and/or resident's representative of the of resident's hospitalization on 07/05/18. Interview with the Administrator on 04/03/19 at 11:45 AM. confirmed the facility did not provide written notification of the bed hold policy to the resident and/or resident's representative upon transfer to the hospital for Residents #5, #17, and #20. Review of policy titled Bed Hold Policy, dated 04/02/18, revealed the facility would provide a copy of the bed hold policy to the resident and/or resident's representative upon transfer to the hospital. 2. Review of Resident #20's medical record revealed an admit date of 10/17/18 with diagnoses including urinary tract infection, osteopathy, chronic obstructive pulmonary disease, dementia, anemia, repeated falls, heart failure, and hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively impaired. Review of a progress note revealed Resident #20 had a fall on 03/29/19 and was sent out to the hospital 9-1-1. Resident #20 returned to the facility 04/01/19 with diagnoses of acute cystitis, acute kidney injury, scalp laceration, and skin tears. Review of the record for Resident #20 revealed the record was silent regarding written notification of the facility's bed hold policy to the resident and/or resident's representative of the of resident's hospitalization on 02/20/19. Based on record review, staff interview, and review of facility policy, the facility failed to provide the resident and/or resident's representative with written notification of the facility's bed hold policy upon the resident's transfer to the hospital. This affected three (Residents #5, #17, #20) of three residents reviewed for hospitalization. The facility census was 64. Findings include: 1. Review of record revealed Resident #5 was admitted on [DATE] with diagnoses which included end stage renal disease. Review of the nursing progress notes, dated 02/20/19 through 02/23/19, revealed the facility was notified that the resident was sent to the hospital from the dialysis center on 02/20/19 for evaluation of a cough. The nursing progress notes revealed Resident #5 was admitted to the hospital on [DATE] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 6 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0625 with a diagnosis of respiratory infection. Level of Harm - Minimal harm or potential for actual harm Review of the record for Resident #5 revealed the record was silent regarding written notification to the resident and/or resident's representative of the facility's bed hold policy at the time of the resident's hospitalization. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 7 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) when admitting a resident with mental illness. This affected one (#30) of seventeen residents reviewed in the final sample. The facility census was 64. Residents Affected - Few Findings include: Review of the medical record for Resident #30 revealed an admit date of 01/26/18. Admitting diagnoses included schizoaffective disorder, psychosis and disorder of adult personality and behavior. The medical record failed to reveal any evidence of PASARR information. Interview on 04/02/19 at 12:56 P.M. with Social Worker #115 reported she would locate and supply the PASARR. Interview on 04/04/19 at 9:48 A.M. with Assistant Director of Nursing Registered Nurse (RN) #48 to request Resident #30's PASARR information. During the exit conference on 04/04/19, the PASARR information for Resident #30 was never provided to the survey team by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 8 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to care plan a seat belt and update a resident's potential for alteration in skin integrity care plan with interventions to prevent the development of pressure ulcers. This affected two (#19 and #39) of 17 residents who were reviewed for care plans in the final sample. Findings include: 1. Review of Resident #19 medical record revealed an admit date of 04/28/18 with diagnosis including but not limited to urinary tract infection, fracture of pelvis, peripheral vascular disease, chronic obstructive pulmonary disease, repeated falls, hypertension, anemia, gastroesophageal reflux disease, dementia, and osteoarthritis left knee. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #19 was cognitively impaired and required extensive assist of one for all activities of daily living except supervision only for eating, no behaviors, and no restraints or alarms. Review of physician orders for April 2018 did not revealed any orders for a seat belt to wheelchair. Review of therapy notes for Resident #19 dated 02/18/19 indicated the resident was assessed for a placement of safety belt on wheelchair to decrease falls anteriorly out of wheelchair. The seat belt was attached to the wheelchair. Review of the resident's care plans revealed the use of the seat belt was not in the resident's care plan. Observation of Resident #19 on 04/03/19 at 4:40 P.M. revealed her sitting in a wheelchair in the common area with a fastened seat belt around her hips and lying on her lap. Interview on 04/03/19 at 4:46 P.M. with State Tested Nurse Assistant (STNA) #100 verified Resident #19 was wearing a seat belt attached to her wheelchair. Interview on 04/03/19 at 4:51 P.M. with Assistant Director of Nursing Registered Nurse (RN) #48 stated Resident #19 needed the seat belt to prevent falls and she was able to release it. RN #48 verified Resident #19 did not have a care plan in place for use of a seat belt. 2. Record review for Resident #39 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness and Parkinson's disease. Review of pressure ulcer risk assessment, dated 02/22/19, revealed the resident was at moderate risk for the development of pressure ulcers. Review of the admission nursing assessment for Resident #39 dated 02/22/19 revealed the resident had no pressure ulcers or open areas upon admission. Review of the Minimum Data Set (MDS) assessment, dated 03/06/19, revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 9 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cognitively impaired and required extensive assistance of staff with activities of daily living. The resident was coded for a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) that was not present upon admission to the facility. Review of the care plan for potential alteration in skin integrity for Resident #39 dated 02/22/19 revealed the following interventions: weekly skin observation, monitor for skin alteration, and use caution during transfers. Further review of the care plan for Resident #39 revealed the care plan did not include the resident's risk factors for the development of pressure ulcers nor did it include resident specific interventions to prevent pressure ulcers. Review of wound progress note dated 03/06/19 revealed Resident #39 had a stage two pressure ulcer to the coccyx measuring 1.7 centimeters (cm.) in length by 0.5 cm. in width by 0.2 cm. depth. Interview with the Director of Nursing (DON) on 04/04/19 at 8:56 A.M. confirmed Resident #39's potential for alteration in skin integrity care plan dated 02/22/19 did not include the resident's risk factors for the development of pressure ulcers nor did it include resident specific individualized interventions to prevent pressure ulcers. Review of the facility policy titled Pressure Ulcer Prevention dated April 2018 revealed the facility would assess each resident for specific individualized risk factors for the development of pressure ulcers and that the resident care plan would be updated as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 10 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to thoroughly investigate falls and ensure the physician ordered and care planned interventions for fall preventions were in place. This affected four (#5, #10, #20 and #25) of four residents reviewed for accidents. The facility policy was 64. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 02/21/13. Diagnoses included subdural hematoma (brain bleeding), hypertension, repeated falls, dysphagia, fracture of right and left arm, heart failure, anxiety, anemia, and dementia. Review of the annual Minimum Data Set (MDS) assessment, dated 01/01/19, indicated Resident #10 was cognitively impaired and required extensive assist of one for all activities of daily living except supervision only for eating. A fall risk assessment dated [DATE] indicated a high risk for falls. Review of Resident #10's April 2019 physician's orders revealed an order for dycem (anti-slid material) to geri-chair every shift. Observation on 04/03/19 at 10:08 A.M. revealed Resident #10 lying in a geri chair in common area. Interview with State Tested Nurse Assistant (STNA) #83 at the time of observation verified Resident #10 should have dycem in her chair and stood the resident and verified Resident #10 did not have dycem in her chair. Interview on 04/03/19 at 3:32 P.M. with Assistant Director of Nursing Registered Nurse (RN) #48 to review Resident #10 falls revealed the facility had incomplete fall investigations. The resident had multiple falls including the following: On 04/16/18, the resident fell at the nurses station. The time was unknown when the resident was last toileted or what time the fall occurred. The new intervention was dycem to her chair. On 07/08/18 at 4:00 P.M., the resident fell from her wheelchair. The fall investigation lacked when the resident was last seen, last toileted, or if the dycem was in her chair at the time of the fall. On 07/23/19 at 5:20 P.M., the resident was found on the dining room floor. The fall investigation lacked if the dycem was in her chair. RN #48 reported staff should have been in the dining room at that time. She stated it was their standard that staff was always in the dining room during meals. On 01/05/19 at 7:26 P.M., the resident was witnessed to fall in the common area when a nurse observed the resident leaning forward in her wheelchair and slid out onto the floor. The fall investigation lacked if the dycem was in her chair or what footwear the resident had on at the time of the fall. RN #48 reported the floor nurse was responsible to write the initial fall report and provide an immediate intervention. RN #48 reported the floor nurse was responsible for all interviews to determine causative factors related to falls. She further stated the unit manager brings the fall information to the every morning clinical meeting for managements notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 11 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 2. Review of Resident #20's medical record revealed an admit date of 10/17/18. Diagnoses included chronic obstructive pulmonary disease, hypertension, repeated halls, and dementia. Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #20 was cognitively impaired and required extensive assist of one for all activities of daily living except supervision only for eating. Residents Affected - Some Review of a care plan, dated 09/02/14, revealed there was not a fall care plan. Further review of the medical record revealed a transfer to the hospital on [DATE] after a fall resulting in a laceration on Resident #20's head. Interview on 04/03/19 at 3:19 P.M. with the Assistant Director of Nursing, RN #48, reported Resident #20 had a witnessed fall in the dining room on 03/29/19 at 12:06 P.M. RN #48 reported Resident #20 returned to the facility 04/01/19 with three sutures in her forehead and the facility added a dycem to her wheelchair as a fall prevention intervention. Observation on 04/03/19 at 4:39 P.M. revealed Resident #20 sitting in her wheelchair in the common area. Interview with STNA #100 at the time of the observation reported knowledge of the resident's last fall and the need for dycem in her wheelchair. STNA #100 stood Resident #20 from her wheelchair revealing the chair did not have dycem in place. RN #77 immediately retrieved dycem and placed it in Resident #20's wheelchair. Interview on 04/03/19 at 5:50 P.M. with the Director of Nursing verified Resident #20 did not have a fall care plan, that all care plans had been discontinued when the resident was sent to the hospital and the fall care plan was missed on initiation of new care planning when she returned to the facility. She produced a care plan dated 04/03/19 which included a fall prevention intervention of dycem to chair. 3. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] with diagnoses which included end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 12/20/18, revealed the resident was cognitively impaired and required extensive assistance of one staff with bed mobility and transfers. Review of the fall risk assessment, dated 03/05/19, revealed the resident was at high risk for falls. Review of the fall care plan, initiated on 10/16/18, revealed the resident was at risk for additional falls due to cognitive loss, poor balance and coordination, cardiac issues, difficulty walking, muscle weakness, dizziness and giddiness with arthritis. Interventions included the following: the call light was within reach, monitor closely as cognitive loss may prevent proper use, respond promptly to requests for assistance and assist with safe positioning. The following intervention was added to the fall care plan on 03/12/19 for his low bed while resident was in bed at all times as tolerated. Review of the nurse progress note for Resident #5 revealed resident fell out of bed on 03/12/19 without injury. Review of the fall investigation, dated 03/12/19, revealed the resident slid out of bed on 03/12/19. Follow up interventions for Resident #5 included to keep bed in the lowest position while in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 12 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 Observation of Resident #5 on 04/02/19 at 4:25 P.M. revealed the resident was in bed with the bed in highest position. Door was open and no staff were present in the room with the resident. The bed was visible from the hallway. Interview with Resident #5 on 04/02/19 at 4:25 P.M. confirmed she had just returned from dialysis and that the transport staff had put her in bed. Observation of Resident #5 on 04/02/19 at 4:27 P.M. revealed State Tested Nursing Assistant (STNA) #101 went into resident's room to check on resident but did not lower the resident's bed. Interview with Resident #5 on 04/02/19 at 4:33 P.M. stated she did not think her bed was supposed to be left in a high position. Observation of Resident #5 on 04/02/19 at 4:35 P.M. revealed Activity Aide #35 went into the resident's room with an activity cart but did not lower the resident's bed. Observation of Activity Aide #35 revealed the aide lowered the resident's bed to lowest position once the resident verbalized that she did not think her bed was supposed to be in the highest position. Interview with Activity Aide #35 on 04/02/19 at 4:35 P.M. confirmed she didn't notice Resident #5's bed was in a high position when she entered the resident's room and that she lowered the bed because the resident had asked her to do so. Interview with STNA #101 on 04/05/19 at 4:45 P.M. confirmed she did not lower Resident #5's bed when she checked on the resident on 04/05/19 at 4:27 P.M. 4. Record review for Resident #25 revealed an admission date of 02/09/16 with a diagnosis of Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/07/19, revealed the resident was cognitively impaired and required extensive assistance of staff with mobility once in the reclining chair. Review of the physician orders for April 2019 for Resident #25 revealed an order to use a geri chair for positioning and comfort as tolerated. Review of the fall care plan, dated 12/07/18, revealed the resident was at risk for falls related to Parkinson's disease. Interventions included use geri chair for positioning. Observation on 04/02/19 at 3:21 P.M. revealed State Tested Nursing Assistant (STNA) #5 pulled Resident #25 down the hallway in his geri chair. Resident #5 was facing backwards while the STNA pulled him from the dirty linen room into the third floor dining room. Interview with STNA #5 on 04/02/19 at 3:22 P.M. confirmed she had pulled Resident #25 down the hallway in his geri chair. Interview further confirmed that Resident #5 was facing backwards while STNA pulled him from the dirty linen room into the third floor dining room. Interview with the Director of Nursing (DON) on 04/03/19 at 11:00 A.M. confirmed residents should be propelled facing forwards in the direction they were going for geri chair transport in order to promote resident safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 13 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 Interview with Physical Therapy Assistant (PTA) #118 on 04/03/19 at 10:33 A.M. confirmed that residents should be propelled facing forwards in the direction they are going for geri chair transport in order to promote resident safety. PTA #188 confirmed that pulling a resident backwards in a geri chair could be potentially hazardous, particularly if the resident was at risk for falls and/or has poor muscle control and that the resident could accidentally slide out of the chair. Residents Affected - Some Review of policy titled Falls Management Program dated 03/15/10 revealed fall prevention should be achieved through an interdisciplinary approach of managing risk factors and and implementing appropriate interventions to reduce falls and that medical professionals, family members, and support staff in the community including housekeeping, maintenance, and dietary etcetera should assist in managing fall risk. Improper use of devices could contribute to falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 14 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to ensure that medications were secured inside the medication carts and did not have loose medications, personal items, food and discontinued blood glucose monitoring test fluids were not stored in the carts. The facility also failed to ensure the medications rooms were clean, orderly and in good repair. This affected three of four medication carts and two of two medications rooms. This had the potential to affect all 64 residents residing in the facility. Findings include: On 04/02/19 at 4:00 P.M., observation of medication cart #1 on the second floor nursing unit was completed. In a small drawer, along with bottles of over the counter medications were loose pills. One large white tablet and eight medium brown tablets. The loose pills were shown to Registered Nurse (RN) #97. RN #97 confirmed that the loose pills should have not been in the drawer. On 04/02/19 at 4:15 P.M., observation of medication cart #2 on the second floor nursing unit revealed the cart contained the following items: cheese crackers, granola bars and multiple packs of cookies. Also observed in the top drawer of the medication cart was a small box containing two vials of solution for testing the blood glucose machines and on the box a date identified as expiration stated 07/2015. These findings were confirmed by RN #54. On 04/02/19 at 4:25 P.M., observation of the second floor medication room revealed the medication room was observed to have a heavily soiled floor, dirt and debris along side the medication refrigerator. Inside the refrigerator, there were dried spills and splatters on the bottom shelf. The sink in the medication room only had one handle to turn on the water, the other handle was missing. The inside walls of the stainless steal sink had a dried build up of a white substance. These findings were also confirmed by RN #54. RN #54 was unaware how long the handle had been broken off of the sink nor able to identify what the dried whit substance was inside the sink. On 04/02/19 at 4:50 P.M., observation of medication cart #2 on the third floor nursing unit revealed the second drawer were two styrofoam cups with paper towels stuffed inside them. Inside each cup was a set of dentures. Stored in this drawer was vaginal cream, nasal spray, topical gel as well as medications for nebulizer inhalation treatments. In the bottom drawer of medication cart #2 were 18 cans of soda, five small containers of applesauce, inhalation medications, fecal occult testing kits, and four cards of medications. The first two cards belonged to Resident #6. Both cards were labeled as containing Amoxicillin (antibiotic) 500 milligrams (mg.). On card #1, there were eight tablets and on card #2 were nine tablets. The other two medications cards were labeled as belonging to Resident #10. Card #1 contained Augmentin (antibiotic) 500-125 mg. and contained three tablets. Card #2 contained Amoxocillin/Clavulanic acid 500 mg./125 mg. This card contained 22 tablets. On 04/02/19 at 5:00 P.M., interview with RN #77 revealed that the medication cards stored in the bottom drawer of medication cart #2 were medication that had been discontinued. When questioned as to the facilities procedure for disposing of medications, RN #77 replied they were suppose to be taken to the medication room to be returned to the pharmacy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 15 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 - Many On 04/03/19 at 8:10 A.M., observation of medication cart #2 on the third floor was observed unattended. The cart was sitting outside of room [ROOM NUMBER]. On top of the cart was a medication card labeled belonging to Resident #11. The medication card contained seven capsules of Doxcycline (antibiotic) 100 mg. Also on top of the cart, there was a bottle of multivitamins. No staff was observed in the area. At 8:15 A.M., RN #77 was observed to exit room [ROOM NUMBER] and come toward the medication cart. RN #77 was questioned as to why medications were unsecured on top of the medication cart. RN #77 picked up the bottle of multivitamins and placed them in the top drawer of the medication cart. RN #77 then picked up the medication card and stated it needed to go to the medication room as it has been discontinued. She stated she hasn't had time to do it yet. Review of the facilities policy and procedure for storage of all drugs and biological's in a safe, secure and orderly manner, dated April 200, revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. The facility shall not use outdated drugs and or biologicals. Drugs shall be locked when not in use and shall not be left unattended. Drugs shall be stored in an orderly manner. Review of the policy and procedure for disposal/ destruction of discontinued medications, dated 2017, revealed once a medication had been discontinued it was to be removed from the resident's medication supply. The facility was to place all discontinued medications in a designated, secure location which was solely for discontinued medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 16 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to serve resident liquids thickened according to the physician's order. This affected one (Resident #39) of one residents reviewed for hydration. The facility census was 64. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] with diagnoses which included muscle weakness, dysphagia, Parkinson's disease, and glaucoma. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 03/06/19 revealed the resident was cognitively impaired and required extensive assistance of staff with eating. Review of the nutrition care plan for Resident #39 initiated 02/24/19 revealed resident was at nutritional risk due to diagnoses which included dysphagia. Interventions included provide diet as ordered. Review of the speech therapy evaluation, dated 02/25/19, revealed the resident was at risk for aspiration and that diet might need to be modified due to medical status. Review of the speech therapy notes dated 03/15/19 revealed the resident had trials with thin liquids and demonstrated forceful coughing and wet vocal quality. Review of the physician order dated 03/19/19 revealed the resident's diet was changed from thin liquids to have nectar thickened liquids due to dysphagia. Review of the tray ticket for Resident #39 for lunch on 04/01/19 revealed the resident was to receive nectar thickened liquids. Review of the discharge instructions for Resident #39 dated 04/02/19 revealed resident's diet order was for nectar thick liquids. Observation of the lunch meal on 04/01/19 at 12:16 P.M. revealed Resident #39 consumed an eight ounce glass of apple juice that had not been thickened. Interview with State Tested Nursing Assistant (STNA) #34 on 04/01/19 at 12:16 P.M. confirmed Resident #39 consumed an eight ounce glass of apple juice that had not been thickened. Interview with STNA further confirmed that she thought resident was supposed to have thickened liquids but that she was not sure. Interview with STNA #5 on 04/01/19 at 12:28 P.M. confirmed that Resident #5 drank an eight glass of apple juice that had not been thickened and that she was not sure what type of liquids the resident was supposed to receive, but that she thought the nurse was finding out. Interview with Registered Nurse (RN) #48 on 04/01/19 at 12:31 P.M. confirmed that the resident had received an order for nectar thickened liquids on 03/19/19 but that subsequent to that order the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 17 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0807 Level of Harm - Minimal harm or potential for actual harm therapist had told the staff the resident could have thin liquids if supervised. RN #48 confirmed that the resident's record was silent regarding resident having thin liquids following the order for nectar thickened liquids on 03/19/19. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 18 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 and staff interview, the facility failed to maintain a clean sanitary environment for food preparation. This had the potential to affect all 64 residents residing in the facility as all residents consumed meals from the kitchen. Findings include: Initial observation tour of the kitchen facilities on 04/01/19 from 8:11 A.M. to 8:45 A.M. revealed the floors were littered with debris under the various tables and shelving areas. The cover base was covered with thick black buildup. A conveyor toaster was covered with dried, gummy brown substance on outer and inner surfaces. There was rust present on the inner shelf and on the conveyor grate and revolving arms. The plate warmer cabinet had thick dried tan substance on inner walls and base where plates sat before use. The table under the conveyor toaster had thick gummy buildup at each crevice and rust covering the joints and extending out to flat surfaces. Interview during the observations with Kitchen Manager #90 verified the findings and rubbed the gummy substance off the toaster in a small area. Observation on 04/02/19 at 9:38 A.M. of the kitchen conveyor toaster revealed clean, shiny outer surfaces with rust still on the grate and revolving arms. The table under the toaster was clean and had freshly sprayed primer where the rust had been, and the plate warmer was clean. Interview on 04/02/19 at 9:43 A.M. with Kitchen Manager #90 stated the facility was attempting to purchase a new toaster conveyor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 19 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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** 2. Record review for Resident #90 revealed an admission date of 03/11/19. Diagnoses included cerebral infarction, diabetes mellitus, dysphagia, ischemic heart disease, chronic kidney disease, osteoporosis, and atrial fibrillation. Review of a 14-day Minimum Data Set (MDS) assessment, dated 03/25/19, indicated Resident #90 was cognitively impaired. Residents Affected - Few Review of April 2019 physician orders revealed an order for tube feeding of Glucerna (a specific brand of tube feed formula) 1.5 at 50 milliliters (ml.) per hour continuous tube feed. Observation and interview on 04/01/19 at 9:02 A.M. of Resident #90 revealed a clear bag with tubing to a pump infusing at a setting of 50 ml. to her gastrectomy tube. The clear bag had a label indicating a date of 03/30/19 at 11:40 A.M. at 50 ml. with initials. Interview on 04/01/19 at the time of observation with State Tested Nurse Assistant #89 verified the bag attached to Resident #90 was dated 03/30/19. Observation 04/01/19 at 9:48 A.M. of Registered Nurse (RN) #61 removing Resident #90's tube feeding bag dated 03/30/19 and hanging a new bag. Interview with RN #61, while she was changing the bag, verified the bag was dated 03/30/19 and reported staff must not have changed the bag on 03/31/19. Interview on 04/03/19 at 5:27 P.M. with RN #77 verified Resident #90 had a open system enteral feeding and reported the system should be changed every 24 hours. Review of the facility policy titled Enteral Feeding, dated 12/01/11, indicated a change in administration sets for open system enteral feedings at least every 24 hours. Based on record review, observation, staff interview and policy review, the facility failed to maintain appropriate infection prevention regarding tube feeding and failed to utilize appropriate hand hygiene during a wound care treatment. This affected one (Resident #38) of four residents observed for pressure ulcer treatments and one ( Resident #77) of two residents observed with a tube feed. The facility identified seven residents with pressure ulcers and three residents who utilize tube feed. The facility census was 64. Findings include: 1. Record review for Resident #38 revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 02/15/19, revealed the resident was cognitively impaired and totally dependent of staff for activities of daily living. Review of physician order for Resident #38 revealed the resident had an order to cleanse pressure ulcer to the right buttock with normal saline and pat dry, apply calcium alginate with silver and cover with dry gauze tegaderm dressing. Observation of a dressing change to his right buttock on 04/02/19 at 3:06 P.M. by Registered Nurse (RN) #77 revealed the nurse removed her contaminated gloves after removing an old dressing from resident's right buttock and immediately donned cleaned gloves. RN #77 did not perform hand hygiene (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 20 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 after removing her contaminated gloves and donning clean gloves. Level of Harm - Minimal harm or potential for actual harm Interview on 04/02/19 at 3:10 P.M. with RN #77 confirmed she did not perform hand hygiene after removing contaminated glove and donning clean gloves during the dressing change for Resident #38. Residents Affected - Few Review of policy titled Dressings, Dry/Clean, dated September 2013, revealed the nurse should wash and dry hands after removing gloves and prior to donning clean gloves during the dressing change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 21 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #10 revealed an admit date of 02/21/13 with diagnoses including cognitive communication deficit, anxiety disorder, dementia and history of falling. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 had severe cognitive deficit and required extensive assist of one for all activities of daily living except eating which required supervision. Observation of Resident #10 on 04/03/19 at 11:47 A.M. revealed she was up in a geri-chair in the common area. The geri-chair folds had pools of thick dried strawberry colored substance and the geri chair seat was spotted with large dried chocolate colored thick pools of substance. Interview on 04/03/19 at 11:50 A.M. with State Tested Nurse Assistant (STNA) #83 verified Resident #10's chair was dirty and immediately transferred Resident #10 to a wheelchair and cleaned the geri chair. 3. Review of Resident #34's medical recorded revealed an admit date of 08/14/18 with diagnosis including congestive heart failure, atrial fibrillation and gastroesophageal reflux disorder. Review of a quarterly MDS assessment, dated 02/24/19, indicated Resident #34 had cognitive impairment and required extensive assist of one for bed mobility, dressing, eating, toileting, hygiene, and extensive assist of two for transfers. Observation on 04/03/19 at 11:55 A.M. revealed Resident #34 was up in a geri-chair in the common area. Resident #34's geri-chair had thick dried splashed of a brownish substance covering the right side and thick debris on the edges. Interview on 04/03/19 at 11:57 A.M. with STNA #100 verified Resident #34's geri-chair needed cleaning. Interview on 04/03/19 at 4:35 P.M. with Registered Nurse #10 reported all spills in the resident chairs would be cleaned when they occurred. Based on record review, observation and staff interview, the facility failed to ensure geri chairs were clean. This affected two (Residents #10 and #34) of 24 residents reviewed for environment. In addition, the facility failed to secure and/or repair a ripped transition strip to the threshold of the third floor dining and activity area. This had the potential to affect all 30 the residents residing on the third floor (Residents #1, #2, #4, #6, #10, #11, #12, #14, #19, #20, #21, #22, #23, #25, #30, #31, #32, #33, #34, #36, #38, #39, #90, #91, #92, #93, #247, #248, #249 and #250). The facility census was 64. Findings include: 1. Review of facility work orders for the past 30 days revealed the work orders did not include the ripped transition strip to the threshold of the third floor dining and activity area. Observations on 04/02/19 at 12:01 P.M. and on 04/03/19 at 8:19 A.M. revealed the transition strip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 22 of 23 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 365812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wellspring Health Center 8000 Evergreen Ridge Drive Cincinnati, OH 45215 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the floor to the threshold of the third floor dining room was ripped with a partially loose piece of rubber strip approximately 12 inches in length, extending into the dining area. Interview with Registered Nurse (RN) #77 on 04/02/19 at 12:01 P.M. confirmed the transition strip was ripped, that she was not sure how long it had been this way, and that she needed to see about taping it down. RN #77 confirmed the ripped transition strip on the floor was a potential trip hazard. Interview with Director of Plant Operations #118 on 04/03/19 at 8:19 A.M. confirmed no work orders had been completed regarding the ripped transition strip to the threshold of the third floor dining and activity area. Further interview confirmed the transition strip to the threshold of the third floor dining room was ripped and that it was a potential trip hazard. Review of the facility's list of residents who resided on the third floor revealed Residents #1, #2, #4, #6, #10, #11, #12, #14, #19, #20, #21, #22, #23, #25, #30, #31, #32, #33, #34, #36, #38, #39, #90, #91, #92, #93, #247, #248, #249 and #250 resided on the third floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 23 of 23