Health inspection·May 18, 2023

F 0569 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #19's account balance dated 05/16/23 revealed Resident #19 had a balance of $3,012.36 in her resident funds account. Review of Resident #19's quarterly statement from 03/02/23 to 05/01/23 revealed Resident #19's account was opened on 03/02/23 and she had an ending balance of $3,012.36 on 05/01/23 and a starting balance of $3,126.03 on 03/14/23. Review of Resident #19's notifications of spend down revealed no spend down notifications were issued from 03/02/23 until 05/15/23. Interview on 05/17/23 at 1:41 P.M. with Licensed Practical Nurse (LPN) #446 verified Resident #19 received Medicaid and the facility did not notify Resident #19 that the amount of funds in the account was 200 dollars less than the social security income resource limit and the residents may lose eligibility for Medicaid or social security income. 3. Review of Resident #31's chart revealed Resident #31 admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. Review of Resident #31's payer source information dated 05/17/23 revealed Resident #31 was on Medicaid. Review of Resident #31's account balance dated 05/16/23 revealed Resident #31 had a balance of $5,781.37 in her resident funds account. Review of Resident #31's quarterly statement from 03/02/23 to 05/03/23 revealed Resident #31's account was opened on 03/02/23 with starting balance of $5,663.31 on 03/14/23 and she had an ending balance of $2,228.00 on 05/03/23. Review of Resident #31's notifications of spend down revealed no spend down notifications were issued from 03/02/23 until 05/15/23. Interview on 05/17/23 at 1:41 P.M. with Licensed Practical Nurse (LPN) #446 verified Resident #31 received Medicaid and the facility did not notify Resident #31/financial representative that the amount of funds in the account was 200 dollars less than the social security income resource limit and the residents may lose eligibility for Medicaid or social security income. Review of the facility's resident trust statements, discharges and Medicaid eligibility policy, dated January 2018, revealed resident accounts must not be allowed to accumulate more than that required total Medicaid allowable amount for continuing Medicaid eligibility. Facility management must notify each resident who receives Medicaid benefits when the amount in the resident's account reaches 200 less than the supplemental security income limit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 2 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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 - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, and staff interview, the facility failed to ensure the resident's skin conditions, discharge locations, and feeding tubes were accurately coded on the Minimum Data Set (MDS) assessment. This affected three (#23, #38, and #52) of 17 residents reviewed for accuracy of assessments. The facility census was 56. Residents Affected - Some Findings include: 1. Review of Resident #23's chart revealed Resident #23 admitted to the facility on [DATE] with diagnoses including muscle weakness and congestive heart failure. Review of Resident #23's physician order dated 04/17/23 revealed Resident #23 was ordered to cleanse the left labia, apply lotrisone cream to open area and cover with hydrocolloid twice a day and as needed for moisture associated skin damage (MASD). Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #23 had no MASD. Interview on 05/17/23 at 9:11 A.M. with Licensed Practical Nurse (LPN) #433 verified Resident #23 had MASD. Interview on 05/18/23 at 9:21 A.M. with Registered Nurse (RN) MDS Coordinator #444 verified Resident #23's MASD was not accurately coded on the MDS assessment on 04/19/23. Review of the facility's certifying accuracy of the resident assessment policy, dated November 2019, revealed the information captured on the assessment reflects the status of the resident during the observation period. 2. Review of the medical record for Resident #38 revealed an admission date of 03/22/22. Diagnoses included cerebral infarction and epilepsy. Resident #38 was admitted to the facility with a percutaneous endoscopic gastrostomy (PEG) tube (allows nutrition and hydration through the PEG tube into abdomen). Review of the care plan dated 01/20/23 revealed Resident #38 had a nutritional problem related to dysphagia, cognitive communication deficit, aphasia, and unintended weight loss. Interventions included staff to administer water flush through g-tube as ordered. Staff to encourage to allow tube flush. Staff to provide and serve supplement/tube feed as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not coded for a feeding tube or abdominal (PEG) tube. Interview on 05/17/23 at 11:11 A.M. with MDS Coordinator #444 verified Resident #38's MDS assessment dated [DATE] was not coded correctly. The MDS assessment should have been coded with Resident #38 had a PEG tube. 3. Review of the medical record for Resident #52 revealed an admission date of 03/13/23 and a discharge date of 03/14/23. Diagnoses included acute respiratory failure with hypoxia and pneumonia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 3 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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 Level of Harm - Potential for minimal harm Residents Affected - Some Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] for Resident #52 revealed Resident #52 was discharged to an acute care hospital. Review of the medical record revealed Resident #52 was discharged home with spouse on 03/14/23 Interview on 05/17/23 at 1:40 P.M. with MDS Coordinator #444 verified Resident #52 was discharged home to the community and not to an acute hospital and verified the MDS assessment on 03/14/23 was inaccurate. Review of the facility policy titled, Certifying Accuracy of the Resident Assessment, dated November 2019 revealed any person completing a portion of the Minimum Data Set (MDS) must sign and certify the accuracy of that portion of the assessment. The information captured on the assessment reflected the status of the resident during the observation period for that assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 4 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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, review of the facility policy, and staff interview, the facility failed to develop care plans for a resident's cognitive impairment, wandering, and activity needs. This affected two (#43 and #47) residents out of 17 residents reviewed for accuracy of assessments. The facility census was 56. Findings include: 1. Review of Resident #47's medical record revealed Resident #47 admitted to the facility on [DATE]. Diagnoses including dementia with psychotic disturbance. Review of the progress note dated 05/02/23 revealed Resident #47 was not found in his room at 9:30 P.M. and Resident #47 had made several attempts to leave his room and floor prior. Resident #47 stated he was going home. Staff later found Resident #47 on the first floor. Resident #47 was moved to the secured unit for the night. The progress note dated 05/03/23 revealed Resident #47's physician was in to see Resident #47 and a new order was added to place a wanderguard on the left ankle. Review of the physician order dated 05/03/23 revealed Resident #47 was to have a wanderguard to his left ankle and to check placement and functioning every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired and Resident #47 was reported to wander. Review of the care plan on 05/16/23 revealed Resident #47 did not have a care plan related to his wandering or dementia. Review of the progress notes dated 05/06/23 revealed Resident #47 was noted wandering on the unit multiple times without his walker or wheelchair. On 05/11/23, Resident #47 became increasingly confused looking for his wife and could not remember where his room was located. On 05/11/23, Resident #47 wandered into another resident's room while social services was doing an evaluation. Interview on 05/18/23 at 9:21 A.M. with Registered Nurse (RN) MDS Coordinator #444 verified Resident #47 did not have a wandering or dementia care plan prior to 05/17/23. 2. Review of Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included rheumatoid arthritis, major depressive disorder, and cognitive communication deficit disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was severely cognitively impaired. Resident #43 required extensive assistance with bed mobility, and transfers. Resident #47 required dependent with dressing, toileting, and personal hygiene, and supervision with eating. Review of Resident #43's care plan dated 05/03/23 revealed Resident #43 did not have an activities care plan at the time of admission or in place at the time of survey. Interview on 05/18/23 at 9:21 A.M. with the Director of Nursing (DON) verified Resident #43 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 5 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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 have an activities care plan prior to 05/17/23. Level of Harm - Minimal harm or potential for actual harm Review of the facility's comprehensive care plan policy dated 01/13/18 revealed the facility will develop a comprehensive care plan no more than seven days after the completion of the comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 6 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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** 2. Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, major depressive disorder, muscle weakness, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Resident #17 required supervision from staff with transfers, dressing, eating, toileting, and personal hygiene. Resident #17 was independent with bed mobility. Review of Resident #17's care conferences from 11/15/22 to 05/18/23 revealed Resident #17 had one care conference completed on 01/04/23. Interview with Resident #17 on 05/15/23 at 10:54 A.M. revealed Resident #17 had not been invited to any care conferences and did not have the opportunity to participate in the development of his care plan. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #17 only had one care conference completed on 01/04/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. 3. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease, dysphagia, hypertension, end stage renal disease, irritable bowel syndrome with constipation, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Resident #35 required supervision from staff with bed mobility, transfers, dressing, toileting, personal hygiene, and eating. Review of Resident #35's care conferences from 11/15/23 to 05/18/23 revealed Resident #35 did not have any care conferences completed. Interview with Resident #35 on 05/15/23 at 10:44 A.M. revealed Resident #35 had not been invited to any care conferences and did not have the opportunity to participate in the development of her care plan. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #35 did not have any care conferences from 11/15/23 to 05/18/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. Based on record review, resident and staff interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected four (#9, #17, #21, and #35) of five residents reviewed for care plans. The facility census was 56. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 11/02/15. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 7 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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 included type two diabetes mellitus, schizoaffective disorder, convulsions, epilepsy, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Resident #21 required supervision from staff with transfers and eating, one-person extensive assistance with dressing and toileting, and one-person total dependence with bathing. Review of the care conferences for the last 12 months for Resident #21 revealed she only had two care conferences completed on 11/04/22 and 01/03/23. Interview on 05/17/23 at 1:50 P.M. with Social Services Director (SSD) #418 verified Resident #21 only had two care conferences dated 11/04/22 and 01/03/23 for the last 12 months. Subsequent interview on 05/17/23 at 2:28 P.M. with SSD #418 revealed the care conferences were now being conducted quarterly, but previously, SSD #418 was only completing the care conferences as needed. 4. Review of the medical record for Resident #9 revealed an admission date of 07/27/19. Diagnoses included end stage renal disease, vascular dementia, metabolic encephalopathy, major depressive disorder, peripheral vascular disease, hypertension, type two diabetes mellitus, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required extensive assistance from staff with transfers, dressing, toileting, and bathing. Resident #9 was incontinent of bowel. Review of Resident #9's care conferences from 09/01/23 to 05/15/23 revealed Resident #9 had one care conference on 04/26/23. Interview with Resident #9 on 05/15/23 at 10:42 A.M. stated he had not been invited to participate in his care planning and he was unsure when or where it had taken place. Interview with Social Services Director (SSD) #418 on 05/17/23 at 2:27 P.M. verified Resident #9 only had one care conference completed on 04/26/23. SSD #418 stated she was doing care conferences as needed but recently started to do care conferences quarterly. Resident #9 was not participating in care planning and only his daughter was participating. Social services provided a hand written note, on plain white paper, without date or signature page of who attended or was invited. Review of the facility policy titled Care Planning - Interdisciplinary Team, dated September 2013, revealed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment (MDS). The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate were encouraged to participate in the development of and revisions to the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 8 of 9 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 365946 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and review of tube feed product and preparation guidance, the facility failed to ensure a resident's tube feed formula was properly dated and stored prior to administration. This affected one (#38) of two residents reviewed for tube feeds. The facility census was 56. Findings include: Review of the medical record for Resident #38 revealed an admission date of 03/22/22. Diagnoses included cerebral infarction and aphasia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was not able to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. Review of the care plan dated 01/20/23 revealed Resident #38 had a nutritional problem related to dysphagia, cognitive communication deficit, aphasia, and unintended weight loss. Interventions included staff to administer water flush through g-tube as ordered. Staff to encourage to allow tube flush. Staff to provide and serve supplement/tube feed as ordered. Review of the physician order dated 12/27/22 revealed Resident #38 was ordered to flush g-tube with 240 milliliters (ml) water every six hours. The physician order dated 04/10/23 revealed Resident #38 was ordered TwoCal HN supplement 240 milliliters (ml) after meals through the percutaneous endoscopic gastrostomy (PEG) (provides nutritiona and hydration through tube to abdomen) related to dysphagia. Observation of the third floor north and south hallway kitchenette on 05/17/23 at 9:46 A.M. revealed the refrigerator was 52 degrees Fahrenheit, and there was a half empty undated bottle of TwoCal NH feeding tube formula that was half full. The bottle was not dated or labeled. Licensed Practical Nurse (LPN) #442 was observed to take the half empty bottle of Two Cal feeding tube formula and pour it into a cup and return the bottle to the refrigerator. Observation on 05/17/23 at 9:47 A.M. of administration of bolus tube feeding revealed LPN #442 proceeded to Resident #38's room and administered the bolus tube feed of TwoCal HN of 240 milliliters (ml) to Resident #38. Interview on 05/17/23 at 10:01 A.M. with Registered Nurse (RN) #422 verified the refrigerator in the third floor north and south hallway kitchenette was 52 degrees Fahrenheit, and there was an opened and undated bottle of TwoCal HN feeding tube formula in the refrigerator. Interview on 05/17/23 at 10:05 A.M. with LPN #442 verified she provided the opened and undated TwoCal HN formula that was in the third floor north and south hallway kitchenette to administer to Resident #38. Review of the product and preparation method for TwoCal HN found at https://www.abbottnutrition.com/our-products/twocal-hn revealed once the recloseable carton is opened, reclose, refrigerate and use within 48 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 9 of 9