Inspection·July 18, 2019

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 2 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to report an injury of unknown origin to the state agency for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including difficulty walking, repeated falls, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained a skin tear to the left elbow and there were no other injuries. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State Tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left hip fracture. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 3 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 4 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to thoroughly investigate an injury of unknown origin for one resident (#63) of five reveiwed for accidents. The facility census was 102. Residents Affected - Few Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including difficulty walking, repeated falls, and vascular dementia without behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained a skin tear to the left elbow and there were no other injuries. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State Tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left hip fracture. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a hip fracture, and an order was received to send the resident to the hospital for treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 5 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's hip fracture was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's hip fracture to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's hip fracture. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's hip fracture was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 6 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 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 - Few 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to properly store and label medications in three of eight medication cabinets observed. This affected three residents (#23, #63 and #96). The facility census was 102. Findings include: 1. Review of Resident #23's physician orders dated [DATE] revealed an order for Humalog Kwikpen 100 units per milliliter (ml) and instruction to administer six units with meals for type two diabetes. Observation on [DATE] at 10:21 A.M., of the medication storage cabinet in Resident #23's room revealed a Humalog Kwikpen 100 units per milliliter (insulin pen) did not have a date opened on the product. Interview with Licensed Practical Nurse (LPN) #53 on [DATE] at 10:23 A.M., confirmed the insulin pen in Resident #23's medication storage cabinet was opened and did not have an open date to ensure that the product was not expired prior to administration. Review of Humalog insulin pen product insert revealed to not use the product past the expiration date printed on the label or for more than 28 days after you first start using the pen. Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed storage recommendations to date when multiple dose vials for injections when opened and discard unused portions after 28 days. 2. Review of Resident #96's physician orders dated [DATE] revealed an order for Polyethyl Glycol-Propyl (Refresh) 0.4-0.3% eye drops to be administered one drop in each eye every eight hours as needed for dry eyes. Observation on [DATE] at 10:00 A.M., of the medication storage cabinet in Resident #96's room revealed a vial of Polyethyl Glycol-Propyl (Refresh) 0.4-0.3% eye drops with an open date of [DATE]. Interview with LPN #53 on [DATE] at 10:02 A.M. confirmed that the Refresh eye drops in Resident #96's medication storage cabinet were dated [DATE]. Review of Refresh eye drops product insert revealed drops can be stored for 28 days after opening to ensure the safety of the drops and beyond 28 days there was a strong risk of the eye drops being contaminated by bacteria which could damage the eyes. Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed to properly handle and dispose of any expired or unused products in accordance with facility policy or local, state, and federal regulations. 3. Observation on [DATE] at 10:09 A.M., of the medication storage cabinet in Resident #63's room revealed a pill vial containing the medication Loratadine (an allergy relief medication) with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 7 of 8 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 365818 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayley Place 990 Bayley Place Drive Cincinnati, OH 45233 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 disregard product by date of [DATE]. Level of Harm - Minimal harm or potential for actual harm Interview with LPN #52 on [DATE] at 10:10 A.M., confirmed the pill vial of Loratadine for Resident #52 was dated [DATE] and was expired. LPN #52 further stated that the nurses go through the resident's medication storage cabinets when they can, however sometimes they were not sure what medications other shifts utilize. LPN #52 took the vial of Loratadine medication and placed it in a cup to be destroyed. Residents Affected - Few Review of the facility's policy titled Medication Storage Guidelines dated [DATE] revealed to properly handle and dispose of any expired or unused products in accordance with facility policy or local, state, and federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365818 If continuation sheet Page 8 of 8