Inspection·May 12, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Review of the facility investigation witness statement dated 03/30/25 of Licensed Social worker, (LSW), #48, revealed on 03/30/25 at approximately 10:45 A.M., Resident #81 was observed standing in RP #11 bathroom with her pants at her ankles and brief pulled up. RP #11 was in a wheelchair and had his hand inside Resident #81's brief. The residents were separated with no resistance. Resident #81 and RP #11 had no response to questioning of the incident. The police were notified and filed a report. Residents Affected - Few Review of the police report dated 03/30/25 at 1:17 P.M. revealed LSW #48 reported at 10:30 A.M. she passed by RP #11 room and observed Resident #81 standing in the bathroom with the briefs intact and pants at ankles. RP #11 was seated in wheelchair with his hand down front of Resident #81's brief. LSW #48 observed no movement, and neither residents were speaking or making any sound, with blank facial expressions. The police advised the guardian to permit Resident #81 to have a SANE examination. Review of the hospital emergency department report dated 03/30/25 at 3:50 P.M. revealed the SANE examination was completed. Resident #81 had some excoriation of the perineum, likely from the use of a diaper. Review of SANE nurse documents dated 03/30/25 at 5:28 P.M., SANE nurse #200 verified LSW #48 report of seeing Resident #81 standing in the bathroom doorway with her pants around her ankles and the assailant's, RP #11, hand in her depends. Neither nursing home resident involved recalling the incident. Resident #81 did not appear in distress and respirations appeared unlabored. Resident #81 appeared clean and well-groomed upon RN #200 arrival. A large area of redness with associated tenderness was observed to the external genitalia, groin, and buttocks, consistent with incontinence associated dermatitis. There was a scant amount of thick white secretions observed to the left labia minora. The SANE RN #200 was able to evaluate the vulva and no lacerations, bruising, or bleeding was observed. There were no further findings. Review of the State Reportable Incident , (SRI) dated 03/30/25 and timed 2:55 P.M., revealed the facility completed a thorough investigation of the incident including witness statement, vulnerable resident skin assessments and staff education on resident abuse. Observations made on 04/02/25 at 11:16 P.M., 04/03/25 at 10:05 A.M., 04/03/25 at 5:55 P.M. and 04/07/2 at 9:25 A.M. and at 12:00 P.M., revealed Resident #81 was in no apparent distress related to the incident of 03/30/25. The resident was clothed, clean and had no odors. Observations made on 04/02/25 at 11:16 P.M. , 04/03/25 at 10:05 A.M. , 04/03/25 at 5:55 P.M. and 04/07/2 at 9:25 A.M. , revealed the FR #11 new room was at end of hall, two halls away from Resident #81 with one- on- one monitoring of Certified Nursing Assistants, (CNA) #100. Interview on 04/02/25 at 10:00 A. M. and on 05/12/25 at 1148 A.M., witness LSW #48 verified on Sunday, 03/30/25, at approximately 10:45 A.M. Resident #81 was standing, coming out of RP #11's bathroom doorway with outwear pants at her ankles and her brief pulled up at her waist. RP #11 was facing Resident #81, sitting in his wheelchair with his hand down her brief. There was no movement of the hand and he removed his hand immediately. There were no verbalizations and flat emotions of both residents. With assistance from RN #43, the residents were separated, assessed and responsible parties were notified. LSW #48 verified Resident #81 was independently ambulatory, able to take herself to the bathroom, and wandered into other resident's rooms. LSW #48 stated RP #11's usual behavior was to sit in his wheelchair at his doorway. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 If continuation sheet Page 2 of 3 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 05/12/2025 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/02/25 at 9:50 A.M., the SANE RN #200 verified she completed the examination of Resident #81 on 03/30/25, and there was no evidence of sexual penetration or injury. There was a reddened rash indicative of an incontinence dermatitis. Interview on 04/07/25 at 10:00 A.M RN #43 verified he was notified of the incident between Resident #81 and RP #11 by LSW #48 on 03/30/25 at approximately 10:50 A.M. RN #43 verified the LSW #48 reported RP #11 had his hand inside Resident #81's brief. The residents were separated and assessed with no injury noted. The police and guardian were notified and the guardian agreed to a SANE examination. Interviews on 04/02/25 at 1:40 P.M., the Administrator and Director of Nursing, (DON) verified Resident #81 and RP #11 had physical contact in RP #11 room on 03/30/25 at approximately 10:45 A.M. , discovered by LSW #48. RP #11 had his hand inside Resident #81's brief. Review of facility policy titled Ohio Abuse, Neglect and Misappropriation , undated, revealed the facility intent is to prevent resident abuse. Sexual abuse is defined as non-consensual sexual contact of any type. This deficiency represents non-compliance investigated under Complaint Number OH00165513. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365892 If continuation sheet Page 3 of 3