Inspection·November 26, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #50's medical record, revealed he was admitted to the facility on [DATE], with diagnoses including Sezary Disease, bacteremia with Methicillin resistant staphylococcus aureus, chronic obstructive pulmonary disease, dysphagia, and schizoaffective disorder. The resident received intravenous antibiotics, Vancomycin, while at the facility. On day 10 of Resident #50's stay at the facility, the resident went to a physician's appointment at a local hospital, accompanied by his mother. At that time, he was directly admitted to the hospital with a diagnosis of sepsis. The resident was later discharged to a local hospice center, due to his diagnosis of terminal cancer/Sezary disease and the family's request for comfort measures. Review of the facility's Bedhold Letter, revealed the resident's mother was sent a letter that stated the amount of bedhold days he had left. Further review of the bedhold days, revealed there was no evidence the office of the Long-Term Ombudsman was notified of resident #50's discharge to the hospital as required. The lack of notice of the Long-Term Ombudsman, was verified by the Regional Director of Operations #50 on 11/26/19 at 3:35 P.M. Based on medical record review and staff interview, the facility failed to provide a copy of the transfer or discharge notification to the Ombudsman for discharges from the facility. This affected two (#12 and #50) of three residents reviewed for discharge notification. The facility census was 54. Findings include: 1. Record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, schizophrenia, essential hypertension, other cerebrovascular disease, gastro esophageal reflux disease, age related osteoporosis, generalized anxiety disorder, vascular dementia without behavioral disturbance, bipolar disorder muscle weakness, abnormal posture and major depressive disorder. Review of Resident #12's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #12 also required supervision with eating on the 10/15/19 MDS. Review of Resident #12's chart revealed resident discharged to the hospital on [DATE] with a left femur fracture and returned to the facility on [DATE]. Further review of Resident #12's chart revealed the Ombudsman was not notified of Resident #12's discharge to the hospital on [DATE]. Interview with the Administrator on 11/26/19 at 8:33 A.M. verified the Ombudsman was not notified of Resident #12's discharge from the facility on 09/12/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to ensure a resident's hospice services were accurately coded on their significant change Minimum Data Sets (MDS) assessment. This affected one (#3) of 18 residents reviewed for accuracy of assessments. The facility census was 54. Residents Affected - Few Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses; congestive heart failure, gastroesophageal reflux disease, diabetes mellitus, muscle weakness, other symbolic dysfunctions, other chronic pain and dysphagia. Review of Resident #3's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #3 also required limited assistance with eating. Further review of Resident #3's 08/29/19 MDS revealed resident did not receive hospice services. Review of Resident #3's chart revealed resident was admitted to hospice on 08/29/19 for a diagnosis of congestive heart failure. Interview with the Administrator on 11/26/19 at 8:33 A.M. verified the Resident #3's hospice services were not accurately coded on Resident #3's MDS dated [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review, observation, and staff interview the facility failed to have physician orders for wound care orders in place on admission. This affected one (#152) out of four residents reviewed for wound care. The facility in-house census was 54. Residents Affected - Few Findings include: A chart review revealed Resident #152 was admitted on [DATE] with diagnosis including left hip replacement, respiratory failure, neuromuscular dysfunction of the bladder, hypotension, hyperlipidemia, intestinal obstruction, depression, hypertension, Methicillin resistance staph areolas, tachycardia, kidney failure, acute cystitis, bacteremia, sepsis, and alcoholic cirrhosis. Review of the five day minimum data set (MDS) assessment dated [DATE] revealed Resident #152 has no cognitive deficits, required limited to substantial assistance with activities of daily living, has a catheter for bladder, and is always continent with bowel. Review of care plan dated 11/20/19 revealed Resident #152 has actual alteration in skin integrity related to dehisced surgical wound to left hip. Review of physician orders revealed there was no orders regarding any dressing changes. Observation on 11/25/19 at 5:25 P.M. with the Director of Nursing (DON) revealed a dressing to Resident #152's left hip was half off and covered with drainage present. Interview during observation on 11/25/19 at 5:25 P.M. with the DON verified that the dressing needed to be changed and she also verified there was no order to change the dressing to Resident #152's left hip. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on personnel file review and staff interview, the facility failed to ensure a state tested nursing assistant (STNA) had an active nurse aide registry. This affected one (#25) out of three STNA personnel files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 54 residents. Findings include: Review of the personnel file of STNA #25, revealed a hire date of 06/21/17. Review of the nurse aide registry, revealed the STNA had an original approval date of 06/26/15 with an expiration date of 08/27/19. There was no updated nurse aide registry verification in the STNA #25's file. During interview with the Human Resources Manager #5 on 11/26/19 at 10:15 A.M., she stated the facility failed to submit STNA #25's required work verification for the past two years. She further stated upon contacting the nurse aide registry staff, she was told to submit proof the STNA had worked at the facility for the past two years along with her 12 hours annual in-service records so she could be placed on the registry. The facility confirmed this had the potential to affect all residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure drug regimen review recommendations were appropriately addressed by the attending physician. This affected one (#33) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: Medical record review revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, coronary artery disease, asthma, osteoarthritis, depression, benign prostatic hyperplasia, anxiety, hypothermia, malnutrition, pain, anemia, hypertension, mood disorder, acute respiratory failure, and hypoxia, gastro-esophageal reflux disease. Review of the Quarterly MDS dated [DATE] revealed that Resident #33 has severe cognitive deficits, requires extensive assistance with activities of daily living, and is always incontinent of bowel and bladder. Review of Pharmacy Monthly Reviews dated 06/2019 proposed to perform a gradual dose reduction for Mirtazapine 15 milligrams (mg) daily, and 07/2019 proposed to perform a gradual dose reduction for Sertraline 50 mg daily revealed no reviewed or acknowledged by physician. Interview on 11/26/19 at approximately 2:30 P.M. with the Regional Director of Clinical Operations (RDCO) #50 verified the physician did not acknowledge the Pharmacy Monthly Reviews dated 06/2019 proposed to perform a gradual dose reduction for Mirtazapine 15 milligrams (mg) daily, and 07/2019 proposed to perform a gradual dose reduction for Sertraline 50 mg daily at all. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview the facility failed to perform gradual dose reduction with anti-psychotic medications. This affected one (#33) out of five residents reviewed for unnecessary medications. Facility census was 54. Findings include: Medical record review revealed Resident #33 was admitted on [DATE] with diagnosis including dementia, coronary artery disease, asthma, osteoarthritis, depression, benign prostatic hyperplasia, anxiety, hypothermia, malnutrition, pain, anemia, hypertension, mood disorder, acute respiratory failure, and hypoxia, gastro-esophageal reflux disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #33 has severe cognitive deficits, requires extensive assistance with activities of daily living, and is always incontinent of bowel and bladder. Review of Pharmacy Monthly Reviews dated 06/2019 proposed to perform a gradual dose reduction for Mirtazapine 15 milligrams (mg) daily, and 07/2019 proposed to perform a gradual dose reduction for Sertraline 50 mg daily revealed no reviewed or acknowledged by physician. Review of physician order dated 07/29/18 revealed an order for Zyprexa (anti-psychotic) five milligrams (mg) one time a day related to anxiety. Continued review of physician order dated 04/26/19 revealed an order for Zyprexa five mg one time daily related to anxiety. Review of physicians orders revealed there was no documentation regarding a gradual dose reduction being conducted for the anti-psychotic medication. Interview on 11/26/19 at 1:04 P.M. with the Director of Nursing (DON) verified that a gradual dose reduction was not completed since Zyprexa five milligrams was ordered on 07/28/18. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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. Based on observation, staff interview, and policy review, the facility failed to remove expired insulin from medication cart. This had to the potential to affect one (#32) out of one resident identified by the facility as receiving insulin on the fourth floor east hall medication cart. Facility census was 54. Findings include: Observations of medication storage on the fourth floor east hall medication cart on 11/25/19 at 1:10 P.M. revealed a Novolog insulin pen opened on 10/22/19 indicating insulin was expired by approximately six days. Interview on 11/25/19 at 1:16 P.M. with Registered Nurse #11 verified that the insulin should have been removed from the medication cart on 11/19/19 due to Novolog was only good for 28 days. The facility confirmed Resident #32 is the only resident on the fourth floor east hall who receives insulin. Review of the Storage of Medication Policy (not dated) revealed all expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview, the facility failed to have accurate physician's orders documented in the resident's medical record. This affected one (#22) of 18 residents reviewed for physician's orders. The facility census was 54. Findings include: Review of Resident #22's medical records revealed an admission dated of 12/12/18 with diagnosis including dementia, depression, schizoaffective disorder, bipolar type, bipolar disorder, hypertension, anxiety, frontotemporal dementia, mood disorder, malignant neoplasm of right female breast, atherosclerotic heart disease of native coronary artery, and symbolic dysfunctions. Review of resident's physician's orders revealed the following orders all initiated on 12/13/18: May go on leave of absence (LOA) supervised., May go on LOA unsupervised., May go out on LOA with meds., and May not go out on LOA. Interview on 11/25/19 at 9:38 A.M. Licensed Practical Nurse (LPN) #13 verified Resident #22 had conflicting orders regarding whether or not the resident may leave the facility. She stated that the facility used standing admitting orders that the admitting nurse appeared to not have selected the correct options. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365925 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Healthcare Center 315 Lilienthal Street Cincinnati, OH 45204 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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, observation and staff interview, the facility failed to resident's call lights were functioning in a manner to allow the resident to call for staff assistance. This affected one (#16) out of the 24 residents reviewed for call light functioning. The facility census was 54. Residents Affected - Few Findings include: Record review revealed Resident #16 was admitted to the facility on [DATE] with the following diagnoses; other obsessive compulsive disorder, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, hypertensive heart and chronic kidney disease without heart failure, muscle weakness, major depressive disorder, psychosis and gastro esophageal reflux disease. Review of Resident #16's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #16 also required supervision with eating. Observation of Resident #16's call light on 11/24/19 at 11:12 A.M. revealed resident's call light located next to her bed did not provide a call to the nurses station or to the light outside of the door. Observation of Resident #16's call light on 11/26/19 at 9:25 A.M. revealed resident's call light located next to her bed did not provide a call to the nurses station or to the light outside of the door. Interview with Licensed Practical Nurse (LPN) #500 on 11/26/19 at 9:25 A.M. verified Resident #16's call light located next to her bed did not provide a call to the nurses station or to the light outside of the door. Interview with the Administrator on 11/26/19 at 1:33 P.M. revealed the facility did not have a policy regarding the functioning of call lights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 10 of 10