Inspection·July 27, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm the facility would notify the physician of changes in clinical condition which included poor glycemic control. Documentation of physician notification should be made in the resident's medical record. This deficiency substantiates Complaint Number OH00113854. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 2 of 21 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 07/27/2022 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete and transmit a significant change Minimum Data Set (MDS) assessment for a resident that was admitted to hospice services. This affected one (Resident #57) of 19 residents reviewed for assessments. The facility census was 93. Residents Affected - Few Findings include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified asthma, chronic obstructive pulmonary disease, aphasia, coronavirus, insomnia, dysphagia, mild cognitive impairment, muscle wasting and atrophy and anxiety disorder. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 05/22/22, revealed the resident was severely cognitively impaired and was totally dependent with bed mobility, dressing, and toileting. Resident #57 required extensive assistance with eating, and personal hygiene and transfers did not occur during the MDS timeframe. Resident #57 was on hospice services. Review of Resident #57's MDS assessments revealed Resident #57 did not have a significant change MDS upon admission to hospice services on 04/21/22. Review of Resident #57's hospice certification and plan of care dated 04/21/22 revealed Resident #57 was admitted to hospice services on 04/21/22 with a diagnosis of cerebral atherosclerosis. During interview on 07/20/22 at 8:12 A.M., the Administrator verified Resident #57 was admitted to hospice services on 04/21/22 and Resident #57 did not have a significant change assessment upon her admission to hospice services. Review of the facility policy titled MDS Responsibilities, dated 06/03/21, revealed the interdisciplinary assessment will be completed for all residents utilizing the guidelines provided in the resident assessment instrument (RAI). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 3 of 21 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 07/27/2022 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 Based on record review, observation, and interview, the facility failed to ensure the resident assessment was accurate regarding the presence of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Residents Affected - Few Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living. Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Observation on 07/18/22 10:51 A.M. of Resident #33 revealed resident had a g-tube inserted in his abdomen. During interview on 07/18/22 at 10:51 A.M., Resident #33 confirmed resident was admitted to the facility with the g-tube and the facility did not provide food or fluids through the tube. During interview on 07/21/22 at 10:27 A.M., Licensed Practical Nurse (LPN) #77 confirmed Resident #33 had a g-tube which was present upon admission. LPN #77 confirmed the MDS for Resident #33 dated 04/21/22 was not accurate regarding the presence of a g-tube. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 4 of 21 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 07/27/2022 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, interview and policy review, the facility failed to ensure dependent residents were provided with adequate toenail care. This affected one (Resident #33) of 19 residents sampled. The census was 93. Residents Affected - Few Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with personal hygiene. Review of admission physician orders for Resident #33 dated 04/14/22 revealed an order for resident to have a podiatry consult. Review of the care plan for Resident #33 dated 05/04/22 revealed resident had an activities of daily living (ADL) self-care performance deficit. Interventions included staff would provide assistance with grooming, dressing, bathing, locomotion, and ambulation. Observation on 07/20/22 at 8:35 A.M. of Resident #33 with Licensed Practical Nurse (LPN) #110 revealed resident's toenails were thick and mycotic and extended approximately one-half inch from the end of the toe. Interview on 07/20/22 at 8:35 A.M. with Resident #33 confirmed he had not had his toenails cut since his admission to the facility in April 2022 and they were getting too long. Interview on 07/20/22 at 8:36 A.M. with LPN #110 confirmed Resident #33's toenails were thick and mycotic and extended approximately one-half inch from the end of the toe. LPN #110 confirmed Resident #33 should have his toenails trimmed by a podiatrist because they were very thick. Interview on 07/21/22 at 8:02 A.M. with the Administrator confirmed Resident #33 had not been seen by a podiatrist during his stay at the facility. Review of the facility policy titled Nail and Hair Hygiene Services dated 02/15/22 revealed residents would have routine nail hygiene as part of the bath or shower and the nurse would inspect the nails and obtain a podiatrist consult if indicated. This deficiency substantiates Complaint Numbers OH00110822 and OH00111259. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 5 of 21 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 07/27/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of information from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to assess and monitor a newly applied lower left extremity immobilizer for a pressure area. This resulted in Actual Harm when Resident #57 was readmitted to the facility with a left lower extremity immobilizer on 03/25/22. The immobilizer was not checked for skin breakdown causing a subsequent avoidable unstageable pressure ulcer that was found on 04/06/22. This affected one (Residents #57) of two residents reviewed for pressure ulcer care. The facility census was 93. Residents Affected - Few Findings included: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified asthma, chronic obstructive pulmonary disease, aphasia, coronavirus, insomnia, dysphagia, mild cognitive impairment, muscle wasting and atrophy and anxiety disorder. Review of Resident #57's quarterly Minimum Data Set (MDS) assessment, dated 05/22/22, revealed the resident was severely cognitively impaired and was totally dependent for bed mobility, dressing, and toileting. Resident #57 required extensive assistance with eating, and personal hygiene and transfers did not occur during the MDS timeframe. Resident #57 had one or more unhealed pressure ulcers or injuries with one Stage III pressure area, two unstageable pressure areas due to coverage of the wound bed by slough or eschar and one unstageable pressure injury presenting as a deep tissue injury. The resident was receiving hospice services. Review of Resident #57's skin care plan, dated 10/06/20, revealed Resident #57 was at risk for altered skin integrity due to moisture secondary to obesity, incontinence, limited mobility, diabetes mellitus and right hemiparesis. Resident #57 had reoccurrence of excoriation under the bilateral breasts, bilateral groin, and abdominal folds due to moisture. Resident #57 refused showers and to get out of bed. Interventions included upper half rails for turning and repositioning while in bed due to flaccid hemiplegia affecting the right dominant side related to cerebrovascular accident (CVA), administer medications as ordered, monitor for side effects and effectiveness of medications, administer treatments as ordered and monitor for effectiveness, assess, record and monitor wound healing, assist resident to reposition the left side every four hours, a low air loss mattress as ordered, monitor nutritional status, serve diet as ordered, monitor intake and record, obtain and monitor lab work as ordered, report results to the physician and follow up as indicated, pressure reduction mattress to bed, trapeze to assist with bed mobility, and treatment as ordered to coccyx. Resident #57's care plan did not contain any documentation related to a lower left extremity immobilizer. Review of the facility's Braden scale dated 01/06/22 revealed Resident #57 was at moderate risk for pressure ulcers. Review of the hospital continuation of care dated 03/25/22 revealed Resident #57 was to wear a lower left extremity immobilizer at least 80 percent of the day and night for three weeks. Review of Resident #57's medical record from 03/25/22 to 04/06/22 contained no documentation that Resident #57's lower left extremity immobilizer was being removed or checked for skin impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 6 of 21 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 07/27/2022 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 0686 Review of the nursing notes dated from 03/25/22 to 04/05/22 revealed no documentation related to Resident #57's lower left extremity immobilizer or checking the lower left extremity immobilizer. Level of Harm - Actual harm Residents Affected - Few Review of the Medication Administration Record and Treatment Administration Record from 03/25/22 to 04/06/22 revealed no orders for skin checks or that any skin checks of Resident #57's lower left extremity immobilizer were completed. Resident #57 received weekly skin checks on 03/31/22 and on 04/06/22. Review of Resident #57's admission initial evaluation dated 03/25/22 revealed direct nursing care was being provided for wound care for a left hip fracture repair. Resident #57 did not have any new skin areas noted. The assessment did not contain any documentation regarding a lower left extremity immobilizer. Review of Resident #57's wound care notes dated 04/01/22 revealed Resident #57 was seen by the wound nurse practitioner on 04/01/22 for a surgical wound to her left hip, an unstageable pressure area to her left buttock acquired prior to admission on [DATE] and a surgical wound to her left knee. Review of Resident #57's weekly skin check dated 04/01/22 revealed resident had skin conditions, changes, ulcers, or injuries. There were no new areas since the last documented skin check. Resident #57 had an area to her coccyx. Resident returned from the hospital with the area and was followed by the wound nurse practitioner weekly. Review of weekly wound evaluations from 04/06/22 to 07/12/22 revealed weekly wound evaluations were completed. Review of the Resident #57's wound evaluation dated 04/06/22 revealed Resident #57 had a device related pressure injury from a lower left extremity immobilizer that was an unstageable pressure ulcer on the posterior ankle. The pressure ulcer was acquired in house. The area was 2.68 centimeters (cm) in length, 7.99 cm in width and was zero centimeters in depth. No odor was present. The wound was 100 percent slough or eschar, and an order was put in place to paint the wound with betadine two times a day and secure with a four by four foam and dry dressing. Resident was to offload the lower left extremity with pillows and heel protector boots and the site was to be monitored closely. Review of Resident #57's wound evaluation dated 07/12/22 revealed Resident #57 had a device related pressure injury from a lower left extremity immobilizer that was an unstageable pressure ulcer on the posterior ankle that was acquired in house on 04/06/22. The area was 10.73 cm in length, 2.59 cm in width and was .10 cm in depth. No odor was present with scant drainage. The wound was 100 percent slough or eschar, and an order was put in place to apply betadine soaked gauze and secure with an abdominal pad and kerlix. Resident #57 was recommended to offload heels, frequent turning and repositioning, optimized nutrition, specialty mattress and to provide frequent incontinence care. Telephone interview on 07/21/22 at 9:31 A.M. with Nurse Practitioner (NP) #900 verified Resident #57's pressure ulcer to left posterior ankle on 04/06/22 was found while doing wound rounds on Resident #57's surgical wounds. NP #900 stated that she found the wound because she saw drainage coming from Resident #57's lower left extremity immobilizer and upon further investigation she found a pressure area to the posterior ankle that was unstageable. NP #900 verified the pressure area to Resident #57's posterior ankle was avoidable because it was caused by her lower left extremity immobilizer and frequent checks and repositioning of the immobilizer and lower left extremity could have prevented the pressure ulcer. NP #900 reported the deterioration of the left posterior ankle wound after it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 7 of 21 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 07/27/2022 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 0686 was discovered was unavoidable due to Resident #57's vascular insufficiency. NP #900 reported Resident #57 was admitted to hospice services after the posterior ankle wound was acquired. Level of Harm - Actual harm Residents Affected - Few Interview with Regional Director of Clinical Operations (RDCO) #901 on 07/21/22 at 10:49 A.M. verified Resident #57 returned from the hospital on [DATE] with a lower left extremity immobilizer. RDCO #901 confirmed Resident #57 did not have an order for the lower left extremity immobilizer and there was no documentation that the lower left extremity immobilizer was checked, taken off or monitored by staff. RDCO #901 verified there was no documentation in the Medication Administration Record or in the Treatment Administration Record regarding the immobilizer or a plan to prevent pressure ulcers with the use of the lower left extremity immobilizer. Review of the NPIAP Pressure Injury Stages undated defined an Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss, Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the facility's skin care and wound management overview policy dated 05/30/19 revealed staff strives to prevent resident skin impairment and to promote healing of existing wounds. The facility will identify diagnoses and conditions that place the resident at risk for pressure ulcer development. The facility will develop a care plan with individual interventions to address risk factors. The facility will communicate risk factors and interventions to the care giving team and will evaluate for consistent implementation of interventions and effectiveness at clinical meeting. This deficiency substantiates Complaint Number OH00110718. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 8 of 21 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 07/27/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm 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 observation, record review and staff interview, the facility failed to ensure residents smoked safely and in designated smoking areas. This affected one (Resident #39) of 39 residents reviewed for smoking. The facility census was 93. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, traumatic subdural hemorrhage with loss of consciousness of unspecified duration initial encounter, unspecified bacterial pneumonia, chronic viral hepatitis C, schizoaffective disorder, difficulty in walking, other psychoactive substance abuse, acidosis, generalized anxiety disorder and nicotine dependence. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and Resident #39 was independent with activities of daily living. Review of Resident #39's smoking care plan dated 05/12/22 revealed Resident #39 used nicotine products and was known to smoke off and in areas that were not designated. Resident #39 was independent with smoking. Interventions included provide safe smoking devices such as smoke aprons, smoke blankets and cigarette extenders and educate the resident to the smoking policy and obtain the resident's signature. Review of Resident #39's smoking assessment dated [DATE] revealed Resident #39 smoked cigarettes. Resident #39 was able to light his own cigarette and had no needs for adaptive equipment. During observation on 07/21/22 at 9:04 A.M., Resident #39 was smoking in the front of the facility next to the signs that stated no smoking. Resident #39 had his surgical mask below his chin while he was smoking a cigarette. During interview on 07/21/22 at 9:04 A.M., Receptionist #67 verified Resident #39 was smoking in a no smoking area with his mask below his chin. Receptionist #67 stated that Resident #39 smokes in the non smoking area without supervision daily despite staff telling him that the area was not a designated smoking area. Review of the facility policy titled Smoking, dated 05/30/19, revealed the facility will promote resident centered care by providing a safe smoking area for residents that request to smoke and are capable of safe smoking either independently or with supervision unless the facility is designated a non smoking facility. Smokers will be permitted to smoke only in designated smoking areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 9 of 21 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 07/27/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on record review, observation, interview and policy review, the facility failed to ensure residents were provided with adequate care and management of gastrostomy tubes (g-tubes.) This affected one (Resident #33) of three residents in the facility with g-tubes. The census was 93. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/14/22 with a diagnosis of malignant neoplasm of the nasal cavity. Review of the Minimum Data Set (MDS) for Resident #33 dated 04/21/22 revealed resident was cognitively intact and required assistance of staff with activities of daily living (ADLs.) Review of section K of the MDS for Resident #33 revealed resident was coded as negative for the presence of a feeding tube. Review of admission nursing assessment for Resident #33 dated 04/14/22 revealed resident had a g-tube in his abdomen present upon admission. Review of monthly physician orders for Resident #33 for July 2022 revealed the orders did not include orders for care and management of resident's g-tube. Review of the dietary progress note for Resident #33 dated 07/14/22 revealed the note did not include documentation regarding the presence of g-tube for resident. Observation on 07/18/22 10:51 A.M. of Resident #33 revealed resident had a g-tube inserted in his abdomen. During interview on 07/18/22 at 10:51 A.M., Resident #33 confirmed resident was admitted to the facility with the g-tube and the facility did not provide food or fluids through the tube. During interview on 07/20/22 at 2:25 P.M., Registered Dietitian (RD) #125 confirmed she was not aware Resident #33 had a g-tube and resident's care plan did not include information regarding care and management of a g-tube, and resident did not have orders for care and treatment of the g-tube and/or what nutrition, if any, should be administered via the g-tube. During interview on 07/21/22 at 10:27 A.M., Licensed Practical Nurse (LPN) #77 confirmed Resident #33 had a g-tube which was present upon admission. LPN #77 further confirmed Resident #33 did not have a care plan for care and management of the g-tube and did not have orders for care and treatment of the g-tube. Review of the facility policy titled Enteral Nutrition Guidelines, dated 01/05/22, revealed the facility would obtain physician orders for care and management of g-tubes which included the type of feeding solution (if any), the amount of feeding solution, frequency of feedings, amount and frequency of flushes, and orders to change dressings to tube insertion site. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 10 of 21 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 07/27/2022 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 - Some 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 record review, observation, interview and policy review, the facility failed to appropriately secure and store resident medications which had the potential to affect all residents on the 400 [NAME] Hall (#2, #3, #5, #12, #17, #18, #19, #20, #32, #35, #36, #40, #41, #43, #46, #47, #52, #53, #54, #61, #63, #75, #81, #87, #88.) The facility also failed to discard expired medication which had the potential to affect all residents receiving medications from the 3 East medication cart (#9, #10, #13, #21, #22, #24, #25, #28, #30, #57, #64, #65, #68, #69, #72, #85, #341, #342) The census was 93. Findings include: 1. Observation on [DATE] at 9:07 A.M. revealed the 400 Hall [NAME] medication cart was unlocked and unattended and there was a plastic cup sitting on top the cart containing two tablets. Interview on [DATE] at 9:13 A.M. with Licensed Practical Nurse (LPN) #130 confirmed she had left the cart unlocked and unattended and the medications sitting on top of the cart included an iron tablet and a vitamin D tablet she had prepared for administration for Resident #40. Further observation on [DATE] at 9:14 A.M. with LPN #130 confirmed the top drawer of the cart included two cups of unidentified loose pills. Interview on [DATE] at 9:14 A.M. with LPN #130 confirmed the first cup included medications she had prepared for administration to Resident #19 (Abilify, gabapentin, ibuprofen, omeprazole, propranolol, tizanidine. LPN #130 confirmed the second cup included medications she had prepared for administration to Resident #41 (amlodipine, lisinopril, Zyprexa.) LPN #130 confirmed the medication cart should be locked when unattended and medications should be not be left unattended. Medications should not be prepoured but should be administered at the time of preparation. Review of the facility policy titled Storage of Medications, dated [DATE], revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label. 2. Review of the medical record for Resident #24 revealed an admission date of [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the [DATE] monthly physician orders for Resident #24 revealed an order dated [DATE] for Flonase nasal spray to be given routinely at bedtime for allergies. Review of the [DATE] Medication Administration Record (MAR) for Resident #24 revealed Flonase was documented as administered every night. Observation on [DATE] at 9:40 A.M. of the 3 East medication cart with Licensed Practical Nurse (LPN) #105 revealed the cart contained an open bottle of Flonase for Resident #24 with a manufacturer's expiration date of 04/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 11 of 21 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 07/27/2022 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 - Some Interview on [DATE] at 9:40 A.M. with LPN #105 confirmed the 3 East medication cart contained an open bottle of Flonase for Resident #24 which had a manufacturer's expiration date of 04/2022. LPN #105 confirmed the Flonase was expired and should have been discarded. 3. Observation on [DATE] at 9:41 A.M. with LPN #105 revealed the 3 East medication cart contained an open house stock bottle of vitamin B complex tablets with a manufacturer's expiration date of 02/2022 and an open house stock bottle of liquid Tylenol with a manufacturer's expiration date of 09/2021. Interview on [DATE] at 9:41 A.M. with LPN #105 confirmed the vitamin B tablets and the liquid Tylenol were expired and should have been discarded. Review of the facility policy titled Storage of Medications, dated [DATE], revealed outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. This deficiency substantiates Complaint Number OH00110654. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 12 of 21 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 07/27/2022 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and review of facility meal times, the facility failed to ensure resident meals were delivered timely. This had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: Observations made on 07/18/22 from 12:30 P.M. to 1:11 P.M. revealed dietary staff delivered meal carts to the 300-Unit at 12:30 P.M., the 400-East Unit at 12:58 P.M., and The 400-West Unit at 1:11 P.M. Observation on 07/20/22 at 1:42 P.M. revealed Dietary staff delivered the meal cart to 400-West Unit. Interviews on 07/18/22 from 10:32 A.M. to 12:16 P.M. Residents #5 and #18 complained that meals were late. Interview on 07/20/22 at 1:48 P.M. State Tested Nurse Aide (STNA) #42 stated when he first started working they made trays in the kitchenette on the unit , but after COVID , it all changed. The kitchen never notified when they make substitutes to the menus and the trays were always late. It happened all the time. During an interview on 07/21/22 at 10:21 A.M. Dietary Manager #42 - stated carts stated meal times included breakfast at 8:00 A.M., lunch at 12:00 noon, and dinner at 5:00 P.M. Dietary Manager #42 stated meal services on 07/20/22 were affected by a call off which threw everything off. Review of document titled Brookside Meal Times no date, revealed breakfast was served at 8:00 A.M., lunch at 12:00 P.M., and dinner at 5:00 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 13 of 21 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 07/27/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure residents received food items as printed on the dietary ticket and the facility failed to provide food portions and therapeutic diets as planned by the dietitian. This affected one (Resident #41) of six residents reviewed for dietary services, and this had the potential to affect 91 of 93 residents who received meals from the kitchen. The facility identified two residents (#27 and #44) who did not received food from the kitchen. The facility census was 93. Findings include: 1. Resident #41 admitted to the facility on [DATE] with diagnoses including schizoaffective disorder bipolar type, paranoid schizophrenia, dementia with behavioral disturbances, Barrett's esophagus without dysplasia, and impulsiveness. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/30/22 revealed Resident #41 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #41 was frequently incontinent of B&B with no toileting program and independent with Activities of Daily Living (ADL's) with setup assistance as needed. Review of the medical record revealed Resident #41 had physician orders dated 07/01/2022 for regular diet with regular texture and consistency. Review of care plan revised 06/28/22 revealed Resident #41 was at risk for nutrition/hydration complications due to diagnoses of dementia, hypertension, Barrett's esophagus, GERD, and constipation. Resident #41 continuously refused weights and had no weight on file. Interventions included medications as ordered, encouraged to comply with weights, report signs/symptoms of malnutrition/dysphagia, serve diet as ordered, offer alternates as needed, document meal intakes, and dietary consult as needed. Review of dietary lunch ticket dated 07/20/22 revealed Resident #41 was ordered hamburger on bun, ketchup, lettuce, tomato, pickle spear, tater tots, cucumber and onion salad, chilled peaches, assorted yogurt cup, and coffee or hot tea. Observation on 07/20/22 at 1:48 P.M. State Tested Nurse Aide (STNA) #42 delivered the lunch tray to Resident #41 . The tray contained a cheeseburger, tater tots, california blend vegetables, a bowl of lettuce, a cup of peaches, a carton of 2 percent milk, and a tumbler of Kool-Aid. During an interview on 07/19/2022 at 8:42 A.M. Resident #41 stated he wanted yogurt with every meal but only received it sometimes. Resident #41 stated he did not always receive all of the items listed on the meal tickets. During an interview on 07/20/22 at 1:48 P.M. STNA #42 verified the contents of Resident #41's lunch tray did not match the dietary ticket. STNA #42 verified there was no cucumber salad and no yogurt on the tray. STNA #42 stated the kitchen never notified when they made substitutes to the menu. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 14 of 21 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 07/27/2022 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 07/20/22 at 1:50 P.M. Resident # 41 verified there was no yogurt, cucumber salad, coffee, pickle, or tomato on the lunch tray. 2. Review of physician ordered diets listed by the facility, there were 21 Consistent Carbohydrate Diets, (CCD), six Therapeutic Lifestyle Changes diets, (TLC), and two Renal Diets. There were six residents identified with puree consistency. Review of breakfast menu spreadsheet dated 07/19/22 revealed the protein portion of the regular diet meal consisted of one biscuit and three ounces of sausage gravy. The CCD, TLC and Renal diets consisted of one fourth cup of scrambled egg. During observation on 07/19/22 at 6:55 A.M., [NAME] #126 served 300 East unit residents on diets of CCD, TLC, and renal diets, one biscuit and three ounces of sausage gravy. During interview on 07/19/22 at 6:55 A.M., [NAME] #126 verified he served the residents ordered on CCD, TLC and renal diets one biscuit and three ounces of sausage gravy. He revealed he did not know what foods to serve the CCD, TLC and renal diets at breakfast, the lunch or the supper meals because he did not have the Registered Dietitian planned spreadsheet to review and follow. He stated he did not prepared foods according to the Registered Dietitian diet plans as he did not know there was a spreadsheet and had not been trained to use a spreadsheet for food preparation and serving foods. He stated he did not know who to contact to clarify the correct foods to prepare for specific diets. During observation on 07/19/22 at 6:55 A.M., [NAME] #126 served pureed biscuits and gravy with a #20 scoop and the spreadsheet listed a #16 scoop. The puree cereal was served with a #16 scoop and the spreadsheet listed a #6 scoop. The puree potato was served with a #16 scoop and the spreadsheet listed a #8 scoop. During interview on 07/19/22 at 7:00 A.M., [NAME] #126 verified he was unaware of how much food to serve and the scoop sizes for the puree diets as he did not have the spreadsheet planned by the Registered Dietitian. Review of policy titled Therapeutic Diets , dated September 2017, revealed all diets are prescribed by the attending physician and diets are prepared in accordance with guidelines of the Diet Manual. This deficiency substantiates Complaint Number OH00111259. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 15 of 21 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 07/27/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to label and date stored foods, discard expired foods and maintain kitchen sanitation. This had the potential to affect 91 residents who received food from the kitchen. The facility census was 93. Findings include: Observation on 07/18/22 at 8:45 A.M. revealed following in the main kitchen areas: 1. No hand soap or drying towels at the employee hand sink 2. Three-hole dish washing temperature log completed to 07/12/22 3. Opened cheese slices undated 4. Opened Medpass supplement undated 5. Open taco sauce dated 03/10/22 6. Nine covered plated salads undated 7. Three sealed meat packages in a pan of water in a sink During interview on 07/18/22 at 8:45 A.M., Assistant [NAME] #49 and Diet Manager, (DM) #42 verified the undated and expired foods. Assistant [NAME] #49 verified the meat should have been thawed running water. [NAME] #126 verified there should have been soap and towels at the employee hand sink. Observation on 07/19/22 at 6:55 A.M. revealed following in the main kitchen areas: 1. The floor drains near the cooking equipment had visible buildup of food debris. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 16 of 21 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 07/27/2022 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 0812 2. Level of Harm - Minimal harm or potential for actual harm The steam table well water had a greasy appearance and food debris in the water 3. Residents Affected - Some The three compartment sink third well drain would not hold sanitizing water. 4. White granulated substance in a closed clear container unlabeled and undated near hand sink. 5. Dishwashing log missing temperatures and concentration of chemical for a low temperature dish machine for dates 07/14/22 through 07/18/22. 6. In dishwashing room, a trash container with lid broken exposing trash. During interview on 07/19/22 at 6:55 A.M., [NAME] #126 verified the floor drain and the steam table had not been clean for over a week. [NAME] #126 was unable to identify the white granulated substance and verified it should be labeled and dated. DM #42 verified the three compartment sink third drain needed repaired During observation on 07/19/22 at 11:55 A.M. revealed a sign attached to the front exterior of the refrigerator dated 12/04/18, No staff food in this refrigerator. Any Resident food must be labeled and dated. Any items not labeled will be pitched daily. There was no temperature log to record refrigerator temperatures. The following was observed in the 300 Unit Resident refrigerator: 1. Three large bags of multiple containers of food unlabeled and undated. 2. Two milk cartons dated expired date of 7/14/22 3. A loaf of open bread undated 4. A gallon closed pitched of red liquid undated and unlabeled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 17 of 21 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 07/27/2022 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 0812 5. Level of Harm - Minimal harm or potential for actual harm Six four ounce closed containers of thick substance unlabeled and undated Residents Affected - Some During interview on 07/19/22 at 11:55 P.M , Licensed Practical Nurse # 110 verified the refrigerator was for resident use only, but employee often use it for food storage. She verified the unlabeled, expired and undated foods. During observation on 07/19/22 at 11:55 A.M. revealed a sign attached to the front exterior of the refrigerator dated 12/04/18, No staff food in this refrigerator. Any Resident food must be labeled and dated. Any items not labeled will be pitched daily. There was no temperature log to record refrigerator temperatures. The following sanitation violations were observed in the 400 Unit Resident refrigerator: 1. Five closed containers of unidentifiable foods which were also undated. 2. Six bags of multiple containers of food unlabeled and undated. 3. Open [NAME] creamer dated 02/11/22. 4. The refrigerator interior had dried food debris on the bottom shelf. 5. Six containers of unopened supplement dated 05/11/22. During interview on 07/19/22 at 11:55 A.M. Licensed Practical Nurse (LPN) # 90 verified the refrigerator was for resident use only but employee often use it for food storage. LPN #90 verified the supplement dated was an expiration date, and the refrigerator needed cleaned. Review of the facility policy, Food Preparation, dated September 2017, revealed foods are to be labeled and dated, equipment sanitized after every use and staff must practice proper hand washing techniques. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 18 of 21 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 07/27/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. Review of the facility COVID-19-line listing dated 07/18/22 revealed Resident #29, #44, #51, residing on the 300 Hall west unit had tested positive for COVID -19 and were currently in droplet isolation. Residents Affected - Many Observation on 07/18/22 at 12:31 P.M. revealed Resident #29 had a sign on his door indicating his room was a red zone and was in droplet isolation. The sign indicated staff should don a fresh N-95 facemask, a face shield, a gown, and gloves before entering. STNA #14 was wearing an N-95 face mask and goggles and she donned a gown and took a lunch tray into Resident #29's room and came back into the hallway. STNA #14 then took a lunch tray into Resident #44 (Resident #29's roommate.) STNA #14 removed the gown in the hallway and discarded it in a trash receptacle in the hallway. STNA #14 then donned a new gown. Observation on 07/18/22 at 12:35 P.M. revealed STNA #14 then took a lunch tray into Resident #66's room who was COVID-19 negative. STNA #14 removed the gown in the hallway and discarded it in a trash receptacle in the hallway. STNA #14 then donned a new gown. Observation on 07/18/22 at 12:40 P.M. revealed Resident #51 had a sign on his door indicating his room was a red zone and he was in droplet isolation. STNA #14 took a lunch tray into Resident #51's room and came out into the hallway and discarded her gown. Interview on 07/18/22 at 12:41 P.M. with STNA #14 confirmed she did not perform hand hygiene between resident rooms, she did not don a new N-95 mask or cover her N-95 mask with a surgical facemask when going from COVID positive rooms in droplet isolation to COVID negative rooms with no isolation precautions. STNA #14 further confirmed she did not don a face shield and she did not sanitize her eye protection goggles after exiting a COVID-19 positive room. STNA #14 confirmed she entered Resident #51's room with her gown hanging loosely over her uniform and she did not properly secure the gown prior to entering a COVID 19 positive room. Review of the facility policy titled Use of Personal Protective Equipment (PPE), dated 03/02/22, revealed in red zone rooms where a resident has a COVID positive diagnosis, full PPE should be worn to include N95 masks, gloves, gown, and eye protection. Staff should discard PPE at the door and eye protection may be cleaned when in exiting between the room patient rooms or new eyewear applied. Based on observation, record review and staff interview, the facility failed to ensure infection control precautions were followed and failed to ensure staff wore personal protective equipment (PPE) to prevent the spread of coronavirus (COVID-19). This affected four (Residents #80, #37, #31 and #33) residents and had the potential to affect all residents it the facility. The census was 93. Findings include: 1. Review of the facility's COVID19 line list revealed Resident #80 tested positive for covid on 07/17/22 and had a cough. Resident #37 did not have covid. During observation of the third floor of the facility on 07/18/22 at 4:09 P.M., Resident #80 was walking in the hall wearing a cloth mas. Resident #80 went to the outdoor smoking area and sat next to Resident #37. Resident #80 and Resident #37 were smoking without a staff member present while sitting approximately three feet apart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 19 of 21 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 07/27/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During interview on 07/18/22 at 4:09 P.M., Licensed Practical Nurse (LPN) #110 verified Resident #80 was sitting next to Resident #37 outside while smoking and were not socially distanced. LPN #110 verified Resident #80 was positive for covid and was on droplet precautions and Resident #37 did not have covid. LPN #110 stated the facility was supposed to have separate smoking times for covid positive residents. 2. Review of the facility's covid list revealed Resident #33 tested positive for COVID19 on 07/17/22 and had a cough. Resident #31 did not have covid. During observation on 07/18/22 at 4:07 P.M., Resident #33 was walking in the hallway. Resident #33 stopped at the nursing station next to Resident #31, who was sitting in her wheelchair. Resident #33 was approximately two feet from Resident #31. Resident #33 was wearing an N95 mask with the bottom strap loose and the top part of the N95 mask below his nose. Resident #31 told Resident #33 to go back to his room because he had COVID and she did not want to get it. During interview on 07/18/22 at 4:07 P.M., LPN #110 verified Resident #31 was not wearing his mask properly. 3. During observation on 07/18/22 at 8:45 A.M., State Tested Nursing Assistant (STNA) #98 was passing food trays from room on the third floor. STNA #98 was not wearing a gown or gloves. She was wearing an N95 mask and face shield. STNA #98 was observed to enter Resident #85's room and place Resident #85's tray on her walker while not wearing a gown or gloves. STNA #98 was observed to sanitize her hands using hand sanitizer and then entered Resident #22's room with his tray without a gown or gloves and place Resident #22's tray on his bedside table. STNA #98 was observed to sanitize her hands with hand sanitizer and then proceeded to enter Resident #341's rom and place her tray on her bedside table without a gown or gloves. STNA #98 was then observed to sanitize her hands with hand sanitizer and then entered Resident #68's room without gown or gloves to deliver his breakfast tray on his bedside table. STNA #98 then sanitized her hands with hand sanitizer and then entered Resident #13's room and place her tray on her bedside table without wearing a gown or gloves. STNA #98 then sanitized hand hands and delivered Resident #23 and #25's tray to their room and left their trays on their bedside tables without wearing gown or gloves. Interview with STNA #98 on 07/18/22 at 8:45 A.M. verified she was passing room trays from room to room and she did not put on a gown or gloves to enter Resident #85, #22, #341, #23 and #25's room despite there being a yellow zone droplet precautions sign stating a gown, gloves, N95 and face shield should be worn to enter Resident #85, #22, #341, #23 and #25's room and a red zone droplet precautions sign stating a gown, gloves, N95 and face shield should be worn to enter Resident #13 and #68's room. STNA #98 stated she was not sure if any of the residents had coronavirus (COVID19). Interview with Licensed Practical Nurse (LPN) #105 on 07/18/22 at 8:45 A.M. verified Resident #13 and Resident #68 were positive for COVID19 and that a gown, gloves, N95 and face shield should be worn to enter their rooms. LPN #105 also verified Resident #85, #22, #341, #23 and #25 were on yellow zone droplet precautions due to exposure and a gown, gloves, N95 and face shield should be worn to enter their rooms. LPN #105 verified STNA #98 did not wear a gown or gloves to enter Resident #85, #22, #341, #68, #13, #23 and #25's rooms. Review of the facility policy titled 'Standard Precautions and Transmission Based Precautions, dated 06/25/21, revealed staff will utilize the proper personal protective equipment upon entering the room of a resident on droplet precautions including using gloves, a mask, and eye protection before (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 20 of 21 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 07/27/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm contracting the resident or environment. Staff will discard the personal protective equipment before leaving the room. 5. Review of the census on 07/18/22 and 07/19/22 revealed there were 50 residents on the East and [NAME] 400 unit. Residents Affected - Many During observation on 07/18/22 at 9:32 A.M. and 07/19/22 at 12:10 P.M. on Unit 400, Licensed Practical Nurse, (LPN) #90 did not wear a surgical or N95 mask. All the resident room doors on the East and [NAME] 400 unit had a sign indicating they were on transmission-based droplet precautions. During interview on 07/18/22 at 1:30 P.M., LPN #90 verified she worked on the 400 unit. She stated she was not wearing a surgical or N95 mask and all the residents were on transmission-based droplet precautions. She stated she did not have to wear a mask because she had a doctor approved medical excuse. This deficiency substantiates Complaint Numbers OH00113968 and OH00112101. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365925 If continuation sheet Page 21 of 21