Inspection·May 8, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete weighed 165 pounds. On 09/05/22, Resident #50 weighed 165 pounds. Further review of Resident #50's weights revealed the resident experienced an 18.1 percent weight loss between 09/2022 and 03/2022. Interview on 04/24/23 at 3:13 P.M., RD #400 verified Resident #50 had a significant weight loss during the 6 months prior to the assessment reference date and verified she had not correctly coded for Resident #50's weight loss for the 6 month period. Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to consistently develop resident centered care plans. This affected two residents (#86 and #91) out of 32 care plans reviewed. The facility census was 101. Findings include: 1. Medical record review revealed Resident #86 was admitted on [DATE] with diagnosis including dementia, hereditary neuropathy, edema, diverticulosis, hypertension, covid, and vitamin B12 deficiency. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 had severe cognitive deficits. Review of the care plans revealed Resident #86 had no care plan implemented after an on 11/23/22 and an elopement care plan was not initiated until 04/10/23 after a second elopement. Interview on 04/20/23 at 11:57 A.M., with the Regional Director of Clinical Operations (RDCO) #427 verified the elopement care plan should have been developed on 11/23/22 and the plan was not developed until 04/10/23. Review of the policy titled Plan of Care Overview undated revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. 2. Review of the medical record of Resident #91 revealed an admission date of 01/19/23. Diagnoses included metabolic encephalopathy, cognitive communication deficit, depression, dementia without behavioral disturbance, Alzheimer's disease, and hearing loss. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #91 had a severe cognitive impairment. The resident was assessed as having moderate difficulty hearing and did not utilize a hearing aid. Review of the Care Area Assessment (CAA) for communication revealed the resident triggered for having moderate difficulty with hearing. Review of the CAA worksheet revealed the resident was at risk for decline in communication and had cognitive decline related to his Brief Interview for Mental Status (BIMS) scores and diagnoses of Alzheimer's. Staff were to monitor for a decline and provide cues and redirection/orientation as needed. Under care plan considerations, the worksheet indicated communication would be addressed in the care plan. Review of the plan of care dated 04/18/23 revealed Resident #91 had a communication problem related to hard of hearing. Interventions included to refer to audiologist for hearing consult as needed. Further review of prior care plans revealed Resident #91's communication deficit had not been addressed prior to 04/18/23. Interview and observation on 04/18/23 at 9:19 A.M., Resident #91 stated he could not hear worth an expletive and had not received any help with getting a hearing aid. Resident #91 was observed to have significant difficulty hearing during the conversation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Interview on 04/20/23 at 11:57 A.M., RDCO #427 verified a communication care plan for Resident #91's hearing impairment was not completed until 04/18/23 and should have been completed following the comprehensive MDS assessment dated [DATE]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 medical record review, staff and family interview, and policy review, the facility failed to ensure residents and resident representatives participated in the plan of care. This affected one resident (#86) out of two residents (#38 and #86) reviewed for care conferences. The facility census was 101. Findings include: Medical record review revealed Resident #86 was admitted on [DATE]. Diagnoses included dementia, hereditary neuropathy, edema, diverticulosis, hypertension, covid, and vitamin B12 deficiency. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #86 had severe cognitive deficits. Review of the care conference notes undated revealed no documentation indicating care conferences were offered or completed. Telephone interview on 04/18/23 at 1:27 P.M., with Resident #86's son reported he had not been invited to a care conference in over a year. Interview on 04/24/23 at approximately 4:00 P.M., with the Regional Director of Clinical Operations #427 verified there was no evidence of care conferences being completed with Resident #86's family. Review of the policy titled, Plan of Care Overview Policy, undated revealed the purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning. This deficiency represents noncompliance in Complaint Number OH00142048. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few 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 medical record review, observations, staff interview, review of witness statements, review of the police report, review of information from Google Maps, review of a weather report, review of the facility investigative files, review of in-service education, and policy review, the facility failed to complete thorough investigations following resident elopements to prevent additional elopements from occurring. Additionally, the facility failed to update residents' elopement assessments and care plans following elopements. Lastly, the facility failed to identify like-residents at risk for elopement to ensure appropriate interventions were in place to potentially prevent the same actions, situations, and/or practices from occurring in the future. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] at an unknown time when Resident #306, who resided on the west hall, exited the facility's secured unit on the south hall through a thirty second egress alarmed door, which lead to an exterior door to exit the building. Resident #306 was found at 2:40 A.M. approximately three-fourths of a mile away from the facility, which was approximately a 14-minute walk. The Immediate Jeopardy continued when Resident #306 exited the secured unit through the same alarmed door on [DATE] at approximately 8:15 A.M. when Maintenance Supervisor (MS) #370 saw Resident #306 walk by the maintenance window and started running down the driveway. Furthermore, the Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egress door on [DATE] without floor staff's awareness. Moreover, the Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE], without staff's awareness, and was found one tenth of a mile from the facility by Receptionist #380. Additionally, the facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. This affected two (#86 and #306) of seven residents reviewed for elopement. Lastly, the facility failed to ensure residents who required the use of a mechanical lift were transferred safely with the assessed amount of staff. This affected one (#32) of 13 residents reviewed for transfers. The facility census was 101. Findings include: On [DATE] at 3:46 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #427 were notified Immediate Jeopardy began on [DATE] at an unknown time when Resident #306 eloped from the facility and was found approximately 14 minutes later around 2:40 A.M. Resident #306 was found by Licensed Practical Nurse (LPN) #341 walking down the side of a two-lane busy road with no sidewalks or streetlights approximately three fourths of a mile away from the facility. Resident #306 was wearing black pants, a red t-shirt, and shoes. The temperature in the area was approximately 55 degrees Fahrenheit (F). Resident #306 refused to go back to the facility with staff, and police were called for assistance. Upon Resident #306's return to the facility, the facility had not updated his elopement care plan to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #306 exited the facility without floor staff awareness on [DATE] and was found by MS #370 running down the driveway. Upon Resident #306's return into the facility, the facility had not updated his wandering observation tool to prevent recurrence. Additionally, the facility had not identified like-residents to ensure appropriate interventions were in place to potentially prevent future elopements. The Immediate Jeopardy continued when Resident #86 exited the secured unit through a thirty second egressed door on [DATE] without floor staff's awareness. The Immediate Jeopardy continued when Resident #86 exited through a thirty second egress door on [DATE] without staff's awareness and was found one tenth of a mile from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few facility by Receptionist #380. The facility failed to follow their elopement policy and did not review and update Resident #86's elopement risk assessment and care plan. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE], the DON/Unit Manager (UM)/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Wandering assessments were updated for all residents, the elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], the DON/UM/Designee completed education with all staff on elopement and acknowledgment of door alarms. Elopement binders were reviewed, updated, and elopement drills were held. On [DATE], the DON/UM/Designee ensured that all residents were accounted for and began to obtain statements from all staff on duty. On [DATE], MS #370 assessed all doors and alarms for functionality without noted deficiency. On [DATE], the DON/UM/Designee completed staff education on elopement and completed an elopement drill. Wandering assessments were updated for all residents with no new elopement risks noted. Elopement binders were reviewed. discharged residents were removed from the elopement binders and any new admissions not previously added, were added to the elopement binders. The medical director was notified of each elopement and agreed with intervention to monitor one-to-one. On [DATE], the elopement binders were reviewed for accuracy. Resident #100 was added to the binder due to an elopement in February 2023. On [DATE], all wandering resident assessments were updated with no changes needed. All care plans were validated and updated with no changes needed. All elopement binders were validated with no changes needed. Wandering assessments are completed upon admission, quarterly, with change in condition, and upon any elopement event. Staff have been educated on elopement. Nurses have been educated on accurately completing wandering assessments, care planning, and timely completion of care plans. On [DATE], RDCO #427 provided education with the DON, the UM, and the Administrator on completing a thorough investigation including staff interviews/witness statements with all staff working the dates of the elopements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few On [DATE], education was provided by the DON/Designee with all staff regarding elopement risk and facility policy. All newly hired staff will be educated. On [DATE], education was provided by RDCO #427/Designee with the licensed nurse to ensure wander observation tools are completed accurately. On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314 and the Minimum Data Set (MDS) staff #375 on ensuring care plans are in place regarding those identified at risk. On [DATE], education was provided by RDCO #427 with the DON, UM #304, #310, and #314, the Administrator, Activity Director #322, Activity Staff #319, #329, #336, #337, and #338, Admissions Coordinator #385, and the Electronic Health Records Clerk #387 to ensure elopement binders are up to date with residents at risk for elopement. On [DATE], LPN #350, State Tested Nursing Assistant (STNA) #369, Receptionist #380 and Maintenance Supervisor #370 stated they had been educated about elopements and responding immediately or as soon as it was safe to do so when alarms sounded. The Administrator/Designee will conduct elopement drills twice weekly on each shift for four weeks, then once a week on each shift for four weeks, then once a week on each shift every two weeks, then monthly for two months. The DON/Designee will audit the elopement binders on each unit to ensure that all residents in the facility are included twice a week for four weeks, then weekly for four weeks, then every other week for four weeks then random observation thereafter. The RDCO #427 will review the completeness of all elopement investigations to ensure that all staff were educated on elopements, elopement binders are updated, and wandering observation tools were completed and accurate. RDCO #427 will review all staff statements to ensure all staff on duty at the time of elopement have provided thorough statements. This audit will occur for all elopements for three months. All variances will be corrected upon discovery, and additional training/follow-up will be provided as deemed necessary. The DON/Designee will bring the results of the audits to the monthly Quality Assurance Performance Improvement (QAPI) meeting. The results of the audit will be reported, reviewed, and trended for a minimum of six months, then randomly thereafter for further recommendations. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #306 revealed an admission date of [DATE] with diagnoses including dementia, schizophrenia, and Parkinson's disease. Review of the MDS assessment dated [DATE] revealed Resident #306 was severely cognitively impaired and required supervision with mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the most recent wandering observation tool dated [DATE] revealed Resident #306 was not at risk for elopement. Further review of the medical record revealed the facility had not completed a wandering observation tool after the elopement on [DATE]. Review of the elopement care plan for Resident #306 updated on [DATE] revealed the resident was an elopement risk related to wandering behavior, diagnoses of Parkinson's, dementia, schizophrenia, and a history of elopement. Interventions included one-to-one supervision until further notice; care conference with the family to discuss a possible transfer ([DATE]), assess hunger, thirst, ambulation, and toileting needs ([DATE]), complete wandering evaluation upon admission/re-admission, quarterly, and as needed ([DATE]), evaluate for need of secured unit and notify medical provider as needed ([DATE]), notify medical provider and resident representative of behavior changes ([DATE]), provide diversionary activities as needed and redirect when appropriate ([DATE]), and provide structured activities at times of increased elopement risk, diversional tasks, redirection of ambulation pattern, and utilization of safe wandering areas ([DATE]). Review of the nurse progress note dated [DATE] at 3:58 A.M. revealed LPN #415 was alerted by State Tested Nurse's Aide (STNA) #349 the door alarm on the south hall was triggered. LPN #415 and STNA #349 went through the alarming door and visualized the main exit door was ajar. LPN #415 and STNA #347 got into their vehicles and drove down the street. Resident #306 was found walking down Springdale Road towards [NAME] Road on the left side approximately a half a mile down the road. The police stopped and helped. Resident #306 was non-cooperative and resisted returning to the facility. Resident #306 was returned by the police. A head-to-toe assessment, neurological checks, vital signs, and nurse's notes were completed. The Director of Nursing (DON) and the family were notified. Review of LPN #341's statement (undated) revealed approximately an hour prior to the incident, Resident #306 was seen on the south hall using the phone. LPN #341 was on lunch when the incident occurred. LPN #341 was heading back from lunch when she saw Resident #306 walking on Springdale Road and called the facility to notify staff and to call the police. Review of STNA #347's statement dated [DATE] revealed at approximately 2:40 A.M., LPN #415 and STNA #420 from west hall came to the south hall to look for Resident #306. STNA #347 began to search for Resident #306. STNA #347 got into his car and drove around the facility looking for Resident #306 but had not found him. STNA #347 drove onto Springdale Road where LPN #341 and STNA #347 found him. STNA #347 did not know how Resident #306 exited the facility because STNA #347 was busy doing rounds and changing other residents. Resident #306 was resistive with staff when trying to bring him back to the facility and made STNA #347 bleed beneath his chin. Review of agency STNA #420's statement dated [DATE] revealed she was alerted by LPN #415 that STNA #349 stated the alarm was going off on the south unit. STNA #349 looked in Resident #306's room, but he was not there. All staff started looking in rooms and hallways and then moved outside of the facility. Resident #306 was found walking down the road. Review of agency staff STNA #425's statement (undated) revealed Resident #306 was walking up and down south hall towards nurse's station, and STNA #425 tried redirecting him to west hall, where he resided, but he refused. STNA #425 asked other staff to help redirect him. STNA #425 went to check on another resident on west hall and noticed Resident #306 was not in his room. STNA #425 asked other staff if they had seen him, and the other staff said no. STNA #425 reported that was when staff started looking for him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Registered Nurse (RN) #318's statement dated [DATE] revealed at 2:40 A.M. she was at north hall nurse's station when the phone rang. The call was from LPN #341 who reported Resident #306 from west hall was walking down Springdale Road, and she needed help to get him back to the facility. RN #318 reported LPN #303 went to help LPN #341 while she called emergency services to meet them on Springdale Road for assistance. RN #318 notified the DON and completed a head count on residents. Review of LPN #303's statement dated [DATE] revealed he received a call from LPN #341 that she found Resident #306 on the road on her way to lunch. LPN #303 went to the road to help bring Resident #306 back to the facility. While trying to bring Resident #306 back to the facility, the police stopped and brought Resident #306 back to the facility. Review of STNA #349's statement dated [DATE] revealed the door alarm on south hall was going off and STNA #349 went to turn off the alarm. STNA #349 went through the alarm door and noticed the door leading outside was open. STNA #349 looked around and had not seen any residents. STNA #349 saw Resident #306 on south hall before the alarm went off, and Resident #306 was nowhere to be found. STNA #349 alerted LPN #415 that Resident #306 got out of the facility. STNA #349 and LPN #415 went back through the door that was alarming and checked the maintenance room and parking lot. LPN #415 got into her car as well as STNA #347 to check the road. STNA #349 stated Resident #306 was found and brought back to the facility. Review of agency LPN #430's statement dated [DATE] revealed she heard door alarms sounding on south hall while she was unclogging a feeding tube in a resident's room. LPN #430 reported as she finished up with resident care, she witnessed LPN #415 and STNA #349 looking for Resident #306. LPN #430 had staff check all rooms and closets. LPN #430 went outside to check the grounds. LPN #415 and STNA #347 got into their cars to search for Resident #306. About twenty-five minutes later, the police and three staff members returned to the facility with Resident #306 in a police car. Review of the police report dated [DATE] revealed a call was placed at 2:43 A.M. for the well-being of Resident #306. On [DATE] at 2:45 A.M. police arrived on scene where Resident #306 was standing in the middle of the road. Staff were unable to get him back to the facility. Police assistance was needed, and Resident #306 was placed into a squad car. On [DATE] at 2:59 A.M. Resident #306 was escorted back to the facility. Review of the in-service provided to staff dated [DATE] revealed staff must immediately react to sounding door alarms. Staff must always investigate to ensure all residents were accounted for and safe. Door alarms may not be deactivated without ensuring all residents had been accounted for. Observations throughout the annual survey revealed the facility's secured door where Resident #306 resided was in working order and alarmed appropriately. Telephone interview on [DATE] at 9:39 A.M., with RN #318 revealed the other nurses went out and looked for Resident #306. RN #318 reported she completed a head count on her unit and notified the DON. RN #318 stated LPN #341 called into the facility and reported Resident #306 was on the road. Telephone interview on [DATE] at 10:09 A.M. with LPN #303 revealed he received a call from LPN #341, who was at lunch, that she saw Resident #306 walking down Springdale Road. LPN #303 reported he turned right out of the facility and met LPN #341 at the gas station. LPN #303 explained he tried to get Resident #306 in his car, but he refused. LPN #303 stated the police were notified and assisted with the return of Resident #306 back to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Telephone interview on [DATE] at 3:31 P.M. with agency STNA #420 revealed she was working west hall where Resident #306 resided. STNA #420 reported Resident #306 got out of the south hall door. STNA #349 came and told LPN #415 that Resident #306 had gotten out of the facility. STNA #420 explained all staff started looking for Resident #306 on south unit, then checked the other units, and checked outside the facility. STNA #420 reported someone called the facility and said Resident #306 was walking down Springdale Road. Residents Affected - Few Telephone interview on [DATE] at 3:36 P.M. with agency LPN #415 revealed Resident #306 was ambulatory on his own and typically walked from unit to unit at night. LPN #415 reported Resident #306 would walk to the south hall and would usually come back after 10 minutes. LPN #415 was working west hall on [DATE], where Resident #306 resided. LPN #415 heard the alarm going off on the south hall but could not recall how long the alarm sounded. STNA #349 notified LPN #415 that Resident #306 got out of the building. LPN #415 and STNA #347 got into their cars and drove in opposite directions down the road looking for Resident #306. LPN #415 reported the streets were very dark at that time. LPN #415 went the opposite direction of where they found Resident #306. Telephone interview on [DATE] at 8:14 A.M. with STNA #349 revealed she saw Resident #306 prior to entering a resident's room to provide care. STNA #349 reported when she came out of the resident's room, the door alarm had been sounding. STNA #349 turned off the alarm and went through the alarming door to see the door to the outside was ajar. STNA #349 looked around and in Resident #306's room but had not seen him. STNA #349 alerted LPN #415 that Resident #306 was missing. STNA #349 and staff looked for Resident #306. LPN #415 and STNA #347 got into their cars and headed down the road. Telephone interview on [DATE] at 8:23 A.M. with agency STNA #425 revealed Resident #306 exited the building when she was providing resident care. STNA #425 reported LPN #341 called into the facility and said Resident #306 was on the street. STNA #425 could not recall any other pertinent information about the incident. Telephone interview on [DATE] at 5:55 P.M. with LPN #341 revealed she had seen Resident #306 prior to the incident wearing different clothes. LPN #341 reported she went to lunch at approximately 2:00 A.M. LPN #341 stated she was on her lunch break when she saw Resident #306 walking down Springdale Road. LPN #341 noticed a man walking down the side of the road with black pants, a red t-shirt, and shoes on. LPN #341 slowed down because she was surprised to see someone walking in a short-sleeved shirt because it was chilly. LPN #341 slowed down and realized it was Resident #306. LPN #341 put on her hazards and yelled his name, but she said he didn ' t slow down or look her way. LPN #341 called into the facility and notified staff that Resident #306 was walking down Springdale Road and to call the police. LPN #341 reported when other staff arrived on scene, she left because she had a passenger in her car. LPN #341 explained the Assistant Director of Nursing (ADON) called her on [DATE] to obtain her statement regarding the incident on [DATE] because the facility misplaced her original statement. Review of the nurse progress note dated [DATE] at 8:32 A.M. revealed Resident #306 exited through the south hall door. RN #314 was notified Resident #306 possibly got out of the facility. RN #314 immediately went out to the parking lot where Resident #306 was with the Maintenance Supervisor (MS) #370. Resident #306 was assisted back to his room. Resident #306 was assessed from head-to-toe without injury noted. The daughter was notified, and Resident #306 was placed on one-to-one supervision. Review of the in-service provided to staff dated [DATE] revealed staff were trained regarding elopement prevention and elopement management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the former Business Office Manager (BOM) #431's statement dated [DATE] revealed she was walking into work around 8:20 A.M. when she saw Resident #306 running out of the maintenance door on the side of the building. As former BOM #431 started towards him, MS #370 immediately followed Resident #306 trying to redirect him. Resident #306 continued to run. Former BOM #431 continued to move towards him to prevent him from going further away from the facility. MS #370 was able to reach him, and Resident #306 stopped running. RN #314 came out to the parking lot and escorted Resident #306 back into the facility. Review of MS #370's statement dated [DATE] revealed at approximately 8:20 A.M., he heard the alarm go off next to the maintenance door. MS #370 saw Resident #306 walking down the sidewalk toward Springdale Road. MS #370 caught up to Resident #306 and was able to redirect him toward the entrance of the facility. Interview on [DATE] at 3:18 P.M. with MS #370 revealed he had not recalled the door alarm going off, but he looked out the window and saw Resident #306 by the south door outside of the facility. MS #370 reported that by the time he got up from the desk and over to the door, Resident #306 was running down the hill on the driveway. Resident #306 was fully clothed but had no shoes, only socks on. MS #370 was shocked Resident #306 did not fall. MS #370 revealed Resident #306 made it approximately 40 to 50 yards from the facility. MS #370 stated the former Executive Director #440 and former BOM #431 met him out in the parking lot for assistance with Resident #306. MS #370 could not recall if any floor staff assisted. Interview on [DATE] at 1:39 P.M. with RDCO #427 verified Resident #306's wandering observation tool was not updated after the elopement on [DATE]. Review of an online map per google maps revealed the gas station near where Resident #306 was found on [DATE] was approximately 0.7 miles from the facility and approximately a 14-minute walk. Review of the online weather resource https://www.accuweather.com/en/us/[NAME]/45243/september-weather/2214995?year=2022 revealed the air temperature was 55 degrees F for the morning of [DATE] for the city in which the facility was located. 2) Resident #86 was admitted on [DATE] with diagnoses including dementia, hereditary neuropathy, hypertension, disorientation, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 had severe cognitive deficits and required supervision with locomotion. Review of the wandering observation tool dated [DATE] revealed Resident #86 was not a risk for elopement. Review of the next wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed the resident was an elopement risk. Review of the wandering observation tool dated [DATE] revealed it was completed with incorrect information revealing the resident was not an elopement risk. Review of a nursing note dated [DATE] at 3:51 P.M. revealed RN #343 was notified by staff Resident #86 was out in the parking lot walking. Resident #86 was seen by the receptionist at that time and was assisted back to the unit by staff and assessed with no injuries. Notifications were made and one-to-one supervision was initiated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the investigation related to the elopement on [DATE] revealed there was no timeline to determine the root cause of how Resident #86 eloped. Resident #86 had no updated plan of care with interventions to prevent elopement. Review of STNA #329's witness statement dated [DATE] revealed two Residents (#16 and #103) were at the south ambulance entrance door touching the door which set off the alarm at the time. Resident #91 informed STNA #329 that Resident #86 was outside. Everyone began looking for Resident #86. Review of a physician order dated [DATE] revealed Resident #86 was placed on increased supervision one-to-one until [DATE] every shift for resident safety. Review of RN #389's witness statement dated [DATE] revealed Resident #91 informed her and another staff member that Resident #86 was outside. RN #389 immediately addressed the situation, running outside to get him. Resident #86 was standing by the cars in the parking lot. No alarms were going off when first notified of the incident. Resident #86 was redirected back to the facility without difficulty. Review of STNA #320's witness statement dated [DATE] revealed she had seen Resident #86 at the south door trying to leave the unit, STNA #320 redirected Resident #86 away from the door and he walked towards the west unit. Review of the former Licensed Social Worker (LSW) #428's witness statement dated [DATE] revealed following the incident, the south ambulance door was alarming with no staff around. LSW #428 and maintenance disarmed the door and ensured the door was locked. Review of STNA #363's witness statement dated [DATE] revealed she saw Resident #86 on the north unit trying to open the door and she redirected him back to his unit. Review of LPN #429's witness statement dated [DATE] revealed Resident #86 kept pushing on the door trying to open it and she asked him to stop pushing on the door. Review of Receptionist #380's witness statement dated [DATE] revealed she was walking past her desk and saw Resident #86 outside and got help. A follow-up interview on [DATE] at 11:57 A.M. with RDCO #427 verified there was no wandering observation tool completed related to the elopement on [DATE] until [DATE]. Review of the nursing note dated [DATE] at 7:40 P.M. revealed Resident #86 was found in the parking lot by Receptionist #380 with a coat, hat, and shoes on. Resident #86 was alert, verbal, and redirected back into the building with no behaviors. Resident #86 was placed on increased one-to-one supervision. Review of the investigation related to the elopement dated [DATE] revealed the incident was not thoroughly investigated and there was no timeline of events to determine a root cause. Review of Receptionist #380's witness statement dated [DATE] revealed she was taking her trash out and walked around the front of the facility and spotted Resident #86 walking towards the end of the driveway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of STNA #348's witness statement (undated) revealed she was providing care to Resident #54 and heard the back door alarm. After STNA #348 finished providing care she checked outside, reset the alarm, and informed the nurse. Review of Nurse Practitioner (NP) #430's note dated [DATE] revealed Resident #86 was seen for follow-up due to dementia with wandering behaviors/elopement. Resident #86 was an [AGE] year-old male with dementia and eloped from the facility over the weekend. Resident #86 was found in the parking lot and redirected back to the facility without difficulty. The plan was to continue one-to-one supervision and follow-up with the psychiatrist as needed for behaviors. Observation and interview on [DATE] at approximately 9:00 A.M., the door on the south unit was alarming continuously and when the surveyor questioned what the noise was, RN #399 stated it was the door alarm and it alarmed all the time because it was broken, and the facility can ' t seem to get it fixed. Observation on [DATE] at 12:15 P.M. with MS #370 revealed the door beyond the keypad 30 second egress door on the south unit, was opened, leading to an open outdoor area. The door was opened and immediately sounded a loud alarm, which sounded for 30 seconds. After 30 seconds, the alarm silenced automatically. No staff were observed to respond to the alarm. MS #370 verified no staff responded to the alarm. Observation on [DATE] at 12:18 P.M. with MS #370 revealed the keypad 30 second egress door on the south unit was pulled and immediately alarmed. The door continued to alarm and was pulled for 30 seconds and then released. The door continued to alarm for an additional three minutes before STNA #325 arrived at the door to respond to the alarm. MS #370 verified staff had not responded to the alarming door for over three minutes. Interview on [DATE] at 12:15 P.M. during observation with MS #370, he reported all egress doors when the alarm was set off was a 30 second delay before the door would open. Interview on [DATE] at 12:18 P.M., two STNAs #302 and #325 stated they could hear the alarm at the nurse's station. STNAs #302 and #325 said there were not enough staff to concentrate on all the door alarms. Interview on [DATE] at 12:30 P.M. with STNA #348 she said she was working on [DATE] when Resident #86 eloped from the building. STNA #348 was in a room two rooms down from the door he eloped from performing care on Resident #54 when she heard the door alarm sound. STNA #348 stated she finished care before checking the alarm which was approximately five minutes. After resident care was completed, she went to the door and looked outside, did not see anyone, reset the door alarm, and went back to work. STNA #348 reported there was not enough staff to check on Resident #86 frequently. Interview on 04/1[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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, interview, review of manufacturer recommendations, and policy review, the facility failed to ensure expired medications were removed from the medication carts. This affected two medication rooms out of two observed, and two medication carts out of three carts observed for expired medications. This had the potential to affect all residents who reside in the facility. The facility census was 101. Findings include: Observation on 04/24/23 at 1:22 P.M. of the west unit cart one with Licensed Practical Nurse (LPN) #315 revealed there was one bottle of stool softener that expired on 10/2022, a bottle of calcium carbonate (a supplement) expired on 11/2022, and a bottle of senna plus (a laxative) that expired on 03/2023. Observation on 04/24/23 at 1:23 P.M. with LPN #315 revealed three vials of tuberculin serum were opened and undated. Interview on 04/24/23 at the time of the observation with LPN #315 verified the expired medications. Observation on 04/24/23 at 1:25 P.M. with LPN #426 of the Mount [NAME] medication cart revealed one bottle of geridryl (antihistamine) expired on 03/2023 and the north wing medication room revealed one vial of tuberculin serum with an open date of 01/12/23. Interview on 04/24/23 at 1:25 P.M., during the observation with LPN #426 verified the medications were expired. Interview on 04/24/23 at 1:30 P.M., with the Assisted Director of Nursing (ADON) #314 verified the medications had expired and were not removed from the carts or rooms. Review of the policy titled Storage of Medications Policy, dated 08/2020 revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory and disposed of according to procedure for medication disposal, and reordered from the pharmacy if a current order exists. Review of the manufacturer recommendation for tuberculin revealed the vial should be discarded after 30 days of opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record review, observations, and staff interviews, the facility failed to ensure dietary staff were competent to fulfill their responsibilities. This had the potential to affect 100 residents who received food from the kitchen. The facility identified one resident (#24) who did not consume any food from the kitchen. The facility census was 101. Findings include: Interview on 04/19/23 at 5:49 P.M. with Culinary Aide #342 revealed he would put his hand in the water from the dishwasher and make an educated guess regarding the temperature. Review of a performance evaluation for Culinary Aide #346 completed on 11/07/22 indicated Culinary Aide #346 had an N for no on the evaluation for testing of parts per million (PPM) for the low temperature dishwasher. Review of a performance evaluation for Culinary Aide #342 completed on 11/08/22 indicated Culinary Aide #342 had an N for no on the evaluation for testing of PPM for the low temperature dishwasher. Interview on 04/20/23 at 3:04 P.M. with [NAME] #372 revealed he was not aware of how to test PPM. Interview on 04/20/23 at 3:13 P.M. with Culinary Aide #342 revealed he was unaware of how to test the PPM for the dishwasher. Interview on 04/20/23 at 3:15 P.M. with Culinary Aide #346 revealed he was unaware of how to test the PPM for the dishwasher. Observation on 04/20/23 at 3:24 P.M. of [NAME] #372 revealed he used a green colored bucket for sanitizing solution. Observation on 04/20/23 at 3:27 P.M. of [NAME] #372 revealed he tested a bucket filled with sanitizing solution with a test strip that showed the solution read at 7.81 milliliters per liter. Interview with [NAME] #372 at the time of the observation indicated the recommended level was 1.17 milliliters per liter. Interview on 04/20/23 at 4:31 P.M. with Mobile Dietary Manager #435 revealed he felt the dietary staff needed additional training regarding their assigned responsibilities. Mobile Dietary Manager #435 stated green buckets should be used for general purpose cleaning and red buckets should be used for sanitizing solution. Mobile Dietary Manager #435 revealed the facility was using Sink & Surface Cleaner Sanitizer Test Strips from Ecolab. Interview on 04/25/23 at 10:47 A.M. with Culinary Director #353 revealed he conducted staff evaluations every six months for dietary employees. Culinary Director #353 indicated he would follow-up with a dietary employee if that employee had not successfully met all competencies on the evaluation. Culinary Director #353 stated he had no documentation of any follow-ups he had conducted with dietary staff as needed based on their performance evaluations. Review of the facility's list of residents who do not receive food from the kitchen revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0801 Resident #24 did not receive food from the kitchen. Level of Harm - Minimal harm or potential for actual harm Review of the Ecolab Sink & Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2020, revealed the approved dilution range of the test strips were between 2.11 and 4.30 milliliters per liter. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 record review, observations, staff interviews, review of facility policies, and review of manufacturer guidelines, the facility failed to ensure the refrigerator was functioning properly, foods were covered and dated, and the chemicals used for sanitation were at the recommended level. This had the potential to affect 100 residents who receive food from the kitchen. The facility identified one resident (#24) that did not consume any food from the kitchen. The facility census was 101. Findings include: Observations on 04/17/23 from 6:35 P.M. to 6:45 P.M. of the walk-in refrigerator revealed undated fruit cocktail, undated ricotta cheese, and an uncovered and undated metal container of sausage. The attached walk-in freezer had an undated bag of frozen ravioli, and two plastic sealable bags of an unknown frozen meat that was undated. Interview with Culinary Aide #455 at the time of the observations confirmed the undated and uncovered items in the refrigerator and freezer. Observation on 04/19/23 at 11:59 A.M. of the walk-in refrigerator revealed a metal container of uncovered chicken breast, which was confirmed by Healthcare Services Group District Manager #450 at the time of the observation. Observation on 04/19/23 at 12:00 P.M. of the walk-in refrigerator revealed the temperature was 60 degrees Fahrenheit (F), which was confirmed by Healthcare Services Group District Manager #450 at the time of the observation. Interview on 04/19/23 at 12:30 P.M. with Maintenance Technician #362 confirmed the walk-in refrigerator had been turned off. Interview on 04/19/23 at 1:30 P.M. with Healthcare Services Group District Manager #450 revealed the refrigerator had been off at least two to three hours for the temperature to be that high. Observation on 04/20/23 at 4:31 P.M. of a sanitizing bucket revealed the test strip indicated the sanitizing concentration was between 5.86 and 7.81 milliliters per liter. Interview with Mobile Dietary Manager #435 at the time of the observation confirmed the level should be between 2.11 to 4.30 milliliters per liter. Review of the facility's list of residents who do not receive food from the kitchen revealed Resident #24 did not receive food from the kitchen. Review of the Ecolab Sink & Surface Cleaner Sanitizer Test Strips How-To Guide, dated 2020, revealed the approved dilution range of the test strips were between 2.11 and 4.30 milliliters per liter. Review of the Healthcare Services Group policy titled Equipment, revised 09/2017, revealed all food service equipment would be clean, sanitary, and in proper working order. Review of the Healthcare Services Group policy titled Food Storage: Cold Foods, revised 04/2018, revealed all perishable food items would be maintained at a temperature of 41 degrees Fahrenheit or below. The policy also revealed that all foods would be stored wrapped or in covered containers and would be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to have a developed Quality Assurance and Performance Improvement Plan (QAPI). This had the potential to affect all 101 residents residing in the facility. Residents Affected - Many Findings include: Review of the facility QAPI program revealed the facility had not developed a QAPI plan for review. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation of a developed QAPI plan. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the QAPI program is ongoing, comprehensive, and encompasses the full range of services offered by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review, staff interview, and policy review, the facility failed to develop and implement action plans to improve performance or address concerns as part of their Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility QAPI program revealed the facility had no documentation regarding any performance improvement plans initiated to addressed identified concerns. Interview on 04/26/23 at 2:54 P.M. with the Director of Nursing (DON) revealed the facility had addressed concerns such as falls and wound management in their clinical meetings. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the facility had no documentation related to performance improvement activities as part of their QAPI program. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed that the facility would track, investigate, and monitor adverse events that must be investigated every time they occur, and action plans will be implemented to prevent a recurrence. The policy also revealed the facility would respond to identified quality and safety concerns using a performance improvement plan developed by the QAPI committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and policy review, the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly. This had the potential to affect all 101 residents residing in the facility. Residents Affected - Many Findings include: Review of QAPI meeting minutes revealed the facility last conducted a QAPI meeting on 08/30/22. Interview on 04/26/23 at 3:21 P.M. with the Administrator confirmed the last documented QAPI meeting was on 08/30/22. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility would conduct a QAPI meeting every month where required members would be present, and any trends or other facility data that required review would be addressed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to provide timely servicing of the resident's equipment. This affected one (Resident #04) of 24 residents reviewed for working equipment. The facility census was 101. Residents Affected - Few Findings include: Review of Resident #04's medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included multiple sclerosis, paraplegia, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had severely impaired cognition and required extensive assistance to total dependence on staff with activities of daily living. An interview on 04/18/23 at 11:51 A.M. with Resident #04 stated he has not been out of his bed in months because the facility took his power wheelchair to fix it and has not brought it back. An observation and interview on 04/19/23 at 1:39 P.M. with Maintenance Director #370 revealed Resident #04's wheelchair was down in storage and not plugged in charging. Maintenance Director #370 stated Resident #04's wheelchair had been in the storage area for a few months, he was under the impression that Occupational Therapist (OT) #410 had ordered a battery and they were just waiting on it. An interview on 04/19/23 at 2:11 P.M. with OT #410 reported the wheelchair had been in storage since 01/25/23 and as of 04/19/23 the battery has not been ordered. OT #410 stated he would visit Resident #04 weekly and stated the resident had been requesting to get up, however he could not get up without his special power chair. OT #410 stated Resident #4 was unable to use another wheelchair due to loss of body control related to his diagnosis so Resident #4's has been in bed since 01/25/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 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 365892 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Burlington House Rehab & Alzheimer's Care Center 2222 Springdale Road Cincinnati, OH 45231 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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on record review, staff interview, and policy review, the facility failed to ensure all staff were properly trained on the facility's Quality Assurance and Performance Improvement (QAPI) program. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the facility records revealed the facility had no documentation of staff training related to QAPI. Interview on 04/26/23 at 4:19 P.M. with the Administrator confirmed the facility had no evidence of QAPI training records for staff. Review of the facility policy titled QAPI (Quality Assurance Performance Improvement) Plan, reviewed 10/01/22, revealed the facility staff would receive training on QAPI upon hire and annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 If continuation sheet Page 23 of 23