Health inspection·January 9, 2024

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. Based on record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for Resident #12. This affected one (#12) out of five residents reviewed for care plans. The facility census was 66. Findings include: Review of medical record for Resident #12 revealed an admission date of 12/11/23. Diagnoses included sequelae of cerebral infarction, burn of unspecified region and vascular dementia. Review of physician orders dated 01/01/24 revealed resident was to receive Eliquis five mg daily due to cerebral infarction, liquid protein two times daily to promote wound healing, Silvadene external cream 1% apply to right lateral thigh, apply adaptic, abdominal dressing and wrap with kerlix daily. Review of the baseline care plan dated 12/12/23 revealed Resident #12 had tested positive for COVID 19 and was at risk for further complications and potentially infecting others, would be free from complications related to infection through the review date and would be free of infection by the review date. There was no information in the baseline care plan dated 12/12/23 related to Resident #12 being on blood thinners and whether she was to remain in the facility long term. There was also no information on the care plan related to a burn injury, treatments, dementia or information related to guardianship or adult protective services being involved with resident's care. Further review of Resident #12's medical record revealed there was no evidence of a comprehensive care plan. Interview on 01/09/24 at 1:21 P.M. with Registered Nurse (RN)/MDS Coordinator #28 revealed Resident #12's comprehensive care plan was not complete as required by CMS, within 21 days from the date of admission. The interview with RN/MDS Coordinator #28 also revealed that the facility expectations for completion of the comprehensive care plan is within 21 days of admission. Interview with RN/MDS Coordinator #28 also confirmed pertinent diagnoses, physician orders, and PASRR information should be included in the care plan and verified. Interview on 01/09/24 at 1:38 P.M. with the Administrator confirmed the comprehensive care plan for Resident #12 was not complete with a completion due date of 12/31/23. The interview with the Administrator also confirmed the facility does not have a policy for care plan completion expectations but that the facilities expectations are within 21 days of admission. This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 2 of 5 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 01/09/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure the dishwasher was properly functioning to ensure the proper sanitation of dishes. This had the potential to affect 65 out of 65 residents who receive their meals from the kitchen, the facility identified one (#62) resident that received no food by mouth/no meals from the kitchen. The facility census was 66. Findings include: Observation of the facility's dishwasher on 01/09/24 at 8:50 A.M. revealed the temperature of the facility's dishwasher was 120 degrees Fahrenheit (F) but the chemicals were zero parts per million (PPM). There was no chemical observed going through the tubing from the chemical tubes to the dishwasher. The dishwasher was not observed to have any leaks. Interview with Maintenance Director #73 on 01/09/24 at 8:50 A.M. verified the temperature of the facility's dishwasher was 120 degrees F and the chemicals were zero parts PPM. Maintenance Director #73 verified the chemical was not entering the dishwasher from the chemical tubs. Interview with the Administrator on 01/09/24 at 11:47 A.M. revealed the facility's dishwasher was leased and the facility did not have the manufacturer instructions. The Administrator verified the dishwasher was a low temperature dishwasher that required chemicals. The Administrator confirmed 65 out of 65 residents residing in the facility receive their meals from the kitchen and there was one (#62) resident that received no food by mouth/no meals from the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00149373. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 3 of 5 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 01/09/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure appropriate personal protective equipment was used in an isolation room. This affected one (#53) out of three residents reviewed for infection control practices. This had the potential to affect 16 (#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58) residents residing on the 3rd floor South Unit floor. The facility census was 66. Residents Affected - Some Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis of Clostridioides difficile (C-diff), anxiety, depression and dementia. Review of Resident #53 physician orders revealed an order dated 01/09/24 for Isolation: C-Diff. Review of lab results for Resident #53 revealed a positive result for Toxigenic C. difficile DNA with a collection date of 01/05/24 and a reported to facility date of 01/08/24. Review of nurse's progress note dated 01/09/24 8:48 A.M. revealed C-diff results positive for Resident #53, physician made aware, contact isolations in place, awaiting new order from physician. Interview on 01/09/24 at 12:38 P.M. with Resident #53 revealed he is not aware of being in isolation precautions but reports no concerns with infection control. Observation on 01/09/24 at 12:40 P.M. revealed State Tested Nursing Assistant (STNA) #51 was in Resident #53's room providing incontinence care to the resident without a gown on. A sign is on the door that reads Please see nurse prior to entering. On the door is a container with gloves available. Outside the door there is a small dresser that is empty. STNA #51 finished peri-care for Resident #53, placing the depends in a clear trash bag with gloves on bilateral hands and a surgical mask on Interview on 01/09/24 at 12:41 P.M. with STNA #51 confirmed she should wear gloves and a gown while in an isolation Resident #53's room who was positive C-Diff. Interview with STNA #51 also confirmed there were no gowns available to use outside of Resident #53's room. STNA #51 confirmed besides providing care for Resident #53 she is also responsible for caring for 16 (#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57 and #58) residents who reside on the 3rd floor South Unit floor. Interview on 01/09/24 at 12:42 P.M. with Licensed Practical Nurse (LPN ) #105 revealed Resident #53 is in isolation for C-Diff, and that the staff need to wear gowns and gloves while in the room providing care. LPN #105 also confirmed there were not any gowns available for the staff to use when going into Resident #53's room. Interview on 01/09/24 at 3:35 P.M. with Administrator revealed in C-Diff isolation rooms staff should wear gloves and a gown while in room. Interview with the Administrator confirmed STNA #51 did not wear a gown while providing peri-care. Review of facility policy titled Isolation-Notices of Transmission-Based Precautions revised August 2019 revealed notices will be used to alert personnel and visitors of transmission-based (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 4 of 5 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 01/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm precautions, while protecting the privacy of the resident. Review of the policy also revealed when transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. Residents Affected - Some This deficiency is based on incidental findings discovered during the course of this complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365946 If continuation sheet Page 5 of 5