Health inspection·August 30, 2022

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. 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, facility policy review, and interview, the facility failed to provide follow up regarding concerns during Resident Council Meetings. This affected two (Resident #07 and #29) out of three residents reviewed for Resident Council concerns. The facility census was 46. Residents Affected - Few Findings include 1. Record review for Resident #07 was admitted to to the facility on [DATE]. His diagnoses included urinary tract infection, chronic obstructive pulmonary disease, diabetes mellitus II, asthma, peripheral vascular disease, vascular dementia, hyperlipidemia, major depressive disorder, spinal stenosis, essential primary hypertension, gastro- esophageal reflux disease, insomnia, and tinea pedis. Resident #07 required an electric scooter for mobility. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed he had intact cognition. Further review of MDS assessment revealed he required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was independent with eating and required no assistance from staff. Interview with Resident #07 on 08/24/22 at 10:40 A.M. with Resident #07 revealed he was concerned with the front door automatic opener not working. Resident #07 stated he is unable to renter the front door to the facility at times because he utilizes a mobility scooter. He stated he reported this issue multiple times including in resident council and no one has addressed the issued. Interview on 08/24/22 at 11:27 A.M. with the Activity Director (AD) #153 confirmed the issue was brought to the Resident Council Attention in May 2022 and July 2022 meeting. AD #153 stated the process following the resident council meetings are to take the resident concerns to each department manager following the resident council meetings and they will address the issue and provide follow up. AD #153 confirmed the issue was never addressed by the facility management team from May 2022 through July 2022. AD #153 stated the only department that appears to follow up on resident council concerns is the nursing department. Interview and observation on 08/24/22 at 2:32 P.M. with the Maintenance Assistant (MA) #217 confirmed the front door access button was not working. MA #217 confirmed the maintenance department could not provide any type of verification regarding the front door automatic door opener needing repair or that it was report between May 2022 through date of survey. 2. Record review for Resident #29 was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus without complications, chronic bronchitis, hyperglycemia, coronavirus 2019 (COVID19), chronic kidney disease, anxiety disorder, alcohol dependence, hypothyroidism, insomnia, major depressive disorder, pneumonia, gastroparesis, diabetes mellitus, and major depressive disorder. Review of the discharge and return anticipated MDS, dated [DATE], revealed Resident #29 had moderately impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, dressing, eating, and personal hygiene. Resident #29 was independent with transfers, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 2 of 10 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 08/30/2022 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident # 29 on 08/24/22 at 10:40 A.M. revealed he was frustrated with the facility for not addressing the issue in his shower. Resident #29 stated he has mold growing in his shower and no one will address the issue. Interview on 08/24/22 at 11:37 A.M. with AD #153 confirmed Resident #29 has reported a concern with his shower having a black substance along the wall and floor of his shower at resident council in March 2022 and in May 2022 resident council meetings. Interview on 08/25/22 at 01:52 P.M. with Housekeeper (HK) #126 confirmed a black substance along the bottom of the shower wall and along the floor of the shower in Resident #29's room. HK #126 stated this is mold. HK #126 stated she continues to try and remove the mold from the shower, however it returns. HK #126 stated the issue was the shower head in the shower. HK#126 held up the shower head and it was dripping a large amount of water. HK #126 stated the moisture from the leak is allowing mold to continually grow in the shower. HK #126 stated she has reported her concern to the maintenance department. HK #126 stated as soon as she cleans the shower the mold returns. Review of the Resident Council notes revealed the front door automatic door opening button was reported as needing repaired in May 2022 and July 2022. Further review of the Resident Council notes revealed the issue with the black substance (Resident #29 referred the black substance as mold) was reported during the council meeting in March 2022 and May 2022. Interview on 08/24/22 at 4:15 P.M. with AD #153 confirmed the dining room/activity, nurse's station, and hallways are always cold. AD #153 confirmed she had to pass blankets out during the afternoon activity on 08/24/22 because the dining/activity room is so cold. AD #153 stated the residents are constantly saying they are cold on the thrid floor unit. All the activities are in the dining room on third floor and it is always cold like that. Interview on 08/25/22 01:36 PM with the Administrator confirmed the expectation of resident council concerns is to be addressed timely each month. The Administrator confirmed the facility has failed to review and resolve concerns brought up during the Resident Council Meeting. Review of the facility policy titled, Housekeeping and Laundry, Resident Room Cleaning Policy, dated 05/14/20, revealed all resident rooms are cleaned and disinfected on a regular basis. Bathroom cleaning stated, clean and disinfect vanity, countertop, sink/bathtub/shower and toilet. Review of the facility policy titled, Resident Council Association, dated 09/09/21, revealed, Resident organization meetings should discuss and document resident concerns and issues. Further review of the facility stated, Resident Council in a skilled nursing facility will follow regulatory guidelines. This deficiency substantiated complaint OH00134607. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 3 of 10 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 08/30/2022 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review, facility policy review, and interview the facility failed to obtain witnessed authorization forms for residents and/or resident representatives allowing the facility to manage their funds in an interest bearing account. This affected four out of four Residents (#12, #13, #15, #19) reviewed for resident funds. The facility census was 46. Residents Affected - Some Findings include Review of the facility resident accounts files for Resident #12, #13,#15, #19 revealed no witnessed authorization forms permitting the facility to manage their funds. Further review of the resident fund accounts for Resident #12, #13, #15, #19 revealed no interest earned on their accounts. Interview on 08/23/22 at 3:33 P.M. with the Business Office Manager (BOM) # 117 confirmed the facility failed to obtain witnessed authorization fund forms from Resident #12, #13, #15,and #19. BOM #117 confirmed no interest was identified on the resident fund account forms for Resident #12, #13,#15, and #19. Review of the facility policy titled, Resident Personal Funds, dated November 2017, the resident has a right to manage his or her financial affairs to include the right to know, in advance, what charges a facility may impose against a resident's personal funds. Further review of the policy revealed if a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage,and account for the personal funds of the resident deposited with the facility. The facility will deposit any resident's personal funds in excess of $100 in an interest-bearing account(or accounts) separate from any of the facility's operating accounts, and will credit all interest earned on resident funds to that account. (In pooled accounts, there must be separate accounting for each resident's share. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 4 of 10 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 08/30/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and interview, the facility failed to provide a homelike environment for three residents (#07, #29, and #30) out of three residents reviewed. The facility census was 46. Findings include 1. Record review for Resident #07 was admitted to to the facility on [DATE]. His diagnoses included urinary tract infection, chronic obstructive pulmonary disease, diabetes mellitus II, asthma, peripheral vascular disease, vascular dementia, hyperlipidemia, major depressive disorder, spinal stenosis, essential primary hypertension, gastro- esophageal reflux disease, insomnia, and tinea pedis. Resident #07 required an electric scooter for mobility. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed he had intact cognition. Further review of MDS assessment revealed he required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was independent with eating and required no assistance from staff. Interview with Resident #07 on 08/24/22 at 10:40 A.M. with Resident #07 revealed he was concerned with the front door automatic opener not working. Resident #07 stated he is unable to renter the front door to the facility at times because he utilizes a mobility scooter. He stated he reported this issue multiple times including in resident council and no one has addressed the issued. Interview on 08/24/22 at 11:27 A.M. with the Activity Director (AD) #153 confirmed the issue was brought to the Resident Council Attention in May 2022 and July 2022 meeting. AD #153 stated the process following the resident council meetings are to take the resident concerns to each department manager following the resident council meetings and they will address the issue and provide follow up. AD #153 confirmed the issue was never addressed by the facility management team from May 2022 through July 2022. AD #153 stated the only department that appears to follow up on resident council concerns is the nursing department. Interview and observation on 08/24/22 at 2:32 P.M. with the Maintenance Assistant (MA) #217 confirmed the front door access button was not working. MA #217 confirmed the maintenance department could not provide any type of verification regarding the front door automatic door opener needing repair or that it was report between May 2022 through date of survey. 2. Record review for Resident #29 was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus without complications, chronic bronchitis, hyperglycemia, coronavirus 2019 (COVID19), chronic kidney disease, anxiety disorder, alcohol dependence, hypothyroidism, insomnia, major depressive disorder, pneumonia, gastroparesis, diabetes mellitus, and major depressive disorder. Review of the discharge and return anticipated MDS, dated [DATE], revealed Resident #29 had moderately impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, dressing, eating, and personal hygiene. Resident #29 was independent with transfers, and toilet use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 5 of 10 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 08/30/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Resident # 29 on 08/24/22 at 10:40 A.M. revealed he was frustrated with the facility for not addressing the issue in his shower. Resident #29 stated he has mold growing in his shower and no one will address the issue. Interview on 08/24/22 at 11:37 A.M. with AD #153 confirmed Resident #29 has reported a concern with his shower having a black substance along the wall and floor of his shower at resident council in March 2022 an May 2022 resident council meetings. Interview on 08/25/22 at 01:52 P.M. with Housekeeper (HK) #126 confirmed a black substance along the bottom of the shower wall and along the floor of the shower in Resident #29's room. HK #126 stated this is mold. HK#126 stated she continues to try and remove the mold from the shower, however it returns. HK #126 stated the issue was the shower head in the shower. HK #126 held up the shower head and it was dripping a large amount of water. HK # stated the moisture from the leak is allowing mold to continually grow in the shower. HK #126 stated she has reported her concern to the maintenance department. HK #126 stated as soon as she cleans the shower the mold returns. 3. Record review for Resident #30 revealed an admission date of 04/22/22. Her diagnoses intracerebral hemorrhage, Covid 19, obesity, asthma, vascular dementia, osteoarthritis, hyperlipidemia, and essential primary hypertension. Review of the quarterly MDS assessment, dated 06/21/22, had intact cognition. Further review of the MDS assessment revealed she was independent and required no assistance from staff with bed mobility, dressing, and eating. Resident #30 required supervision assistance from staff with bed transfers, and toilet use. Interview on 08/24/22 at 10:40 A.M. revealed Resident # 30 reported the dining room/activity room is always cold. Resident #30 stated the management staff is very aware of the thrid floor dining room/activity room, nurse's station and hallways being very cold. Interview on 08/24/22 at 11:37 A.M. with the AD#153 confirmed the dining room/activity room on the 3rd floor is always cold. AD #153 confirmed management staff is aware of the cold temperature on the floor. Observation on 08/24/22 at 12:15 P.M. reveled Resident # 30 was seated in the dining room with a winter coat on eating her lunch. Interview and observation on 08/24/22 at 2:20 P.M. with MA #217 confirmed the dining room/activity room temperature reading was 68. MA #217 stated he is unable to make everyone happy. MA #217 stated if they will complain its cold and then turn around and state its hot. MA #217 confirmed the residents seated in the dining room/activity room were wrapped in blankets or had coats on because the room was so cold. MA #217 walked into the mechanical room and confirmed the third floor temperature reading was 68. Review of the Resident Council notes revealed the front door automatic door opening button was reported as needing repaired in May 2022 and July 2022. Further review of the Resident Council notes revealed the issue with the black substance (Resident #29 referred the black substance as mold) was reported during the council meeting in March 2022 and May 2022. Interview on 08/24/22 at 4:15 P.M. with AD #153 confirmed the dining room/activity, nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 6 of 10 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 08/30/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few station, and hallways are always cold. AD #153 confirmed she had to pass blankets out during the afternoon activity on 08/24/22 because the dining/activity room is so cold. AD #153 stated the residents are constantly saying they are cold on the thrid floor unit. All the activities are in the dining room on third floor and it is always cold like that. Interview on 08/25/22 01:36 PM with the Administrator confirmed the expectation of resident council concerns is to be addressed timely each month. The Administrator confirmed the facility has failed to review and resolve concerns brought up during the Resident Council Meeting. Review of the facility policy titled, Housekeeping and Laundry, Resident Room Cleaning Policy, dated 05/14/2020, revealed all resident rooms are cleaned and disinfected on a regular basis. Bathroom cleaning stated, clean and disinfect vanity, countertop, sink/bathtub/shower and toilet. Review of the facility policy titled, Resident Council Association, dated 09/09/21, revealed, Resident organization meetings should discuss and document resident concerns and issues. Further review of the facility stated, Resident Council in a skilled nursing facility will follow regulatory guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 7 of 10 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 08/30/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that resident medical records provided an accurate depiction of resident medication administration. This affected one resident (Resident #353) of 17 residents reviewed for medications. The facility census was 46. Findings included: Review of the medical record for Resident #353 revealed an admission date of 05/09/22 and a discharge date of 06/13/22 with diagnoses including fracture of the left radius, left femur, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #353 was cognitively intact and was independent for eating, required supervision for personal hygiene, limited assistance of one for bed mobility, walking, and locomotion, and extensive assistance of one for dressing and toileting. Review of physician's orders revealed from 05/10/22 to 05/16/22 an order for Ativan tablet 0.5 milligram (mg) (Lorazepam) Give one tablet by mouth every 24 hours as needed for anxiety Give one tab PO Q HS PRN ( as needed) for anxiety Physician's order from 05/16/22 to 05/31/22 Ativan tablet 0.5 mg (Lorazepam) Give one tablet by mouth every 24 hours as needed for anxiety Give one tab PO Q HS PRN for anxiety. Physician's order from 05/31/22 to 06/13/22 Lorazepam tablet 0.5 mg Give one tablet by mouth two times a day for anxiety. Review of handwritten paper prescription revealed Lorazapam + po HS/PRN anxiety with 30 tablets ordered. Review of electronic medication administration record (eMAR) for 05/2022 revealed Ativan was administered once a day on 05/13 to 05/17, 05/21, 05/25, 05/29, and 05/31, for a total of eight doses in 05/2022. Review of eMAR for 06/2022 revealed Ativan was administered twice a day from 06/01 to 06/12, and once on 06/13/22, for a total of 25 doses in 06/2022, combined number of 33 doses. Review of Controlled Drug Receipt for Resident #353's Ativan 0.5 mg, revealed order as Give 1 tablet by mouth at bedtime as needed. Ativan was administered as follow; administrations not noted in eMAR are designated with *: 05/11 at 1:30 A.M.*, 05/13 at 7:16 P.M., 05/14 at 9:00 P.M., 05/15 at 8:00 A.M., 05/15 at 9:00 P.M.*, 05/16 at 8:00 P.M., 05/17 at 8:22 P.M., 05/18 at 8:05 P.M.*, 05/19 at 7:00 P.M.*, 05/21 at 7:00 P.M., 05/22 at 8:00 P.M.*, 05/25 at 7:00 P.M., 05/28 at 8:00 P.M.*, 05/29 at 7:56 P.M., 05/30 at 8:30 P.M.*, and 05/31 at 9:00 P.M. Seven doses of Ativan were not documented in the 05/2022 eMAR, total of 16 doses administered during 05/2022. Doses of Ativan administered in 06/2022 were all documented on both eMAR and Controlled Drug Receipt for a total of 42 doses from 05/10/22 to 06/13/22 of 67 possible doses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 8 of 10 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 08/30/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A medication administration was observed during the annual survey beginning on 08/22/22, 26 medication opportunities were observed without any significant error and a 0% medication error noted overall. Interview on 08/25/22 at 10:15 A.M. Unit Manager (UM) #139 stated that Resident #353's initial Lorazepam order was written for 14 days as it was as needed (PRN) and when she reordered it for 06/2022, she made the doses scheduled. UM #139 verified that the eMAR orders and pharmacy orders did not match, nor was the handwritten paper prescription contain a properly written order, + po HS/PRN anxiety. She stated that the physician used the forward slash / to mean and, which led to the interpretation of at bedtime and as needed for anxiety, she verified that that was not an acceptable abbreviation for prescription, just that it was how that physician wrote prescriptions. UM #139 verified that the eMAR and Controlled Drug Receipt sheets did not match, noting specifically that 05/11, 05/15, 05/18, 05/19, 05/22, 05/28, and 05/30/22 doses were not documented in the eMAR. Observations from 08/22/22 to 08/25/22 revealed no resident to appear improperly or overmedicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 9 of 10 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 08/30/2022 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 Based on staff interview, review of the Centers for Medicare and Medicaid Services (CMS) memo, review of the infection control log, and policy review, the facility failed to implement a program to prevent Legionella (a type of pneumonia caused by bacteria). This had the potential to affect all residents at the facility. The facility census was 46. Residents Affected - Many Findings include Review of the facility policy packet titled, Water Program, dated 12/29/17 included a plan to reduce the risk for growing and spreading Legionella. Maintenance will provide a continuous review of the water management system. The water management program revealed no evidence of a water management team, roles of the team, no evidence of a description of the building water system. The policy revealed to make sure the program was running and the design was effective. Interview on 08/24/22 at 10:45 A.M., and at 2:32 P.M., Maintenance Director #217 revealed he had no documentation of implementing the water management plan/program. Interview on 08/25/22 at 1:36 P.M., the Administrator verified the facility had failed to implement a program to prevent Legionella. Review of the CMS memo dated 06/02/17 revealed facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. Review of the infection control log for the last 12 months revealed no residents had contracted Legionella. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365812 If continuation sheet Page 10 of 10