Health inspection·March 28, 2019

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interviews, review of personnel files, policy review and review of a job description, the facility failed to ensure licensed practical nurses (LPN) were intravenously (IV) certified when providing medications through a peripherally inserted central catheter (PICC). This affected one (#34) out of two residents who receive medications administered via a PICC line. The facility identified two residents who receive medications administered via PICC line. Facility census was 62. Residents Affected - Few Findings include: Review of the medical record for the Resident #34, revealed an admission date of 01/03/19. Diagnoses included but not limited to osteomyelitis, atrial fibrillation, heart failure, major depressive disorder, diabetes, gangrene and gastro esophageal reflux disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, revealed the resident was cognitively intact and the Brief Inventory of Mental Status (BIMS) score was 15. Resident required supervision only for all ADLs. Review of physician's orders for Resident #34 dated 03/05/19, revealed an order for Cefepime (antibiotic) two grams intravenously every 12 hours for 23 days. Physician orders also notes to infuse over 30 minutes. Review of March 2019 Medication Administration Records (MAR) for Resident #34, revealed LPN's that were not certified for IV administration, administered cefepime via a PICC line. LPN #144 administered medications via PICC line on 03/06/19, 03/07/19, 03/11/19, 03/12/19, 03/20/19 and 03/21/19. LPN #147 administered medications via PICC line on 03/07/19, 03/08/19, 03/22/19 and 03/25/19. Review of personnel records for LPN's #144 and #147, revealed an active license with Board of Nursing under State of Ohio and there was no disciplinary actions in files. Further review of board of nursing license verification website, LPN's #144 and #147 had an active LPN licensed. LPN's #144 and #147 had certifications for medications only. Interview with DON on 03/27/19 at 5:45 P.M., verified LPN's #144 #147 were not IV certified to administered medications via a PICC line. The DON also verified LPN #144 administered medications via PICC line on 03/06/19, 03/07/19, 03/11/19, 03/12/19, 03/20/19 and 03/21/19. DON verified LPN #147 administered medications via PICC line on 03/07/19, 03/08/19, 03/22/19 and 03/25/19. Review of an undated policy titled administering medications, revealed only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Review of LPN/Charge nurse job description revealed primary purpose of job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Job description also indicated implement and maintain established nursing objectives and standards. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 2 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on personnel file review and staff interview, the facility failed to ensure a state tested nursing assistant (STNA) received 12 hours of annual in-services and an annual performance evaluation. This affected one STNA (#30) of the four STNA's reviewed. This had the potential to affect all 62 residents residing in the facility. Facility census was 62. Residents Affected - Many Findings include: Review of STNA #30's personnel file revealed the staff members date of hire was 10/05/16. Further review of STNA #30's personal filed revealed there was evidence of STNA #30 completing 12 hours of in-services annually. Additionally, STNA #30 also did not have an annual performance evaluation in file. Interview with Human Resources Coordinator on 03/28/19 at 2:36 P.M. verified STNA #30 did not have 12 hours of in-services and/or an annual performance evaluation. The facility confirmed this had the potential to affect all residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 3 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to ensure residents medication regimen was free from unnecessary medications regarding as needed orders for psychotropic medication that were not limited to 14 days. This affected three residents (#49, #36 and #27) out of five Residents reviewed for unnecessary medications. The facility census was 62. Findings include: 1. Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnosis including heart failure, atrial fibrillation, pneumonia, acute kidney failure, hypertension, diabetes, hyperlipidemia, glaucoma, anemia, dysphagia, muscle weakness, insomnia, dementia, depression, aphasia, hypothyroidism, urinary tract infection, cerebral infarction, and ataxia. Review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #49 has severely impaired cognitive skills, requires total dependence with all activities of daily living, and always incontinent of bowel and bladder. Review of physician order dated 03/25/19 revealed to give Seroquel 12.5 milligrams (mg) tablet eternally every 12 hours as needed (PRN) for anxiety, restlessness for six months. Further review physician order dated 02/15/19 revealed to give Seroquel 12.5 mg by mouth every 12 hours PRN for restlessness/anxiety. Order discontinued on 03/13/19. Interview on 03/26/17 at 4:00 P.M. with the Director of Nursing (DON) verified that the physician order was for PRN Seroquel 12.5 mg was for 60 days, however there was no stop date. 2. Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnosis including schizophrenia, cerebral infarction, pneumonitis, viral hepatitis C, bipolar disorder, asthma, and cardiac arrhythmia. Review of the Medicare 60-Day MDS dated [DATE] revealed Resident #36 has severely impaired cognitive skills, total dependence with toileting, bed mobility, extensive assistance with transfers, dressing, personal hygiene, and is frequently incontinent of bowel and bladder. Review of physician order dated 01/26/19 to give Xanax 0.5 mg by mouth every four hours PRN for anxiety. Chart was silent of end date and documentation of need for Xanax 0.5 mg. Pharmacy Review Date 02/18/19 recommended a new order for PRN Xanax 0.5 mg every four hours PRN. The Medical Director replied on 03/07/19 disagree it was for Anxiety and to monitor. Interview on 03/26/17 at 4:00 P.M. with the DON verified there was no stop date for the order dated 01/26/19 for Xanax 0.5 mg every four hours PRN. 3. Review of the record for Resident #27 revealed she was admitted [DATE] with diagnoses to include ataxic gait, hypertension, type 2 diabetes, hyperlipidemia, constipation, intervertebral disc degeneration of the lumbar region, schizoaffective disorder, anxiety disorder, recurrent depressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 4 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few disorders, osteoarthritis, non-toxic thyroid nodule, vitamin B-12 deficiency anemia, insomnia, chronic kidney disease, hypertensive heart disease with heart failure, dementia with behavioral disturbance, atrial fibrillation and candidiasis. Review of her Minimum Data Set (MDS) quarterly dated 02/01/19 revealed her Brief Interview for Mental Status was not conducted and she was documented as severely impaired for decision making. Further review of her MDS revealed she required extensive assistance for eating, Activities of Daily Living (ADL's), bed mobility and transfers, Review of her current Physician's orders for March revealed an order for Ativan 0.5 milligrams every six hours as needed with a start date of 12/03/18. Review of the Medication Regimen Review dated 02/18/19 revealed the pharmacy recommended evaluating the current diagnosis, behaviors and usage patterns and evaluate the continued need for Ativan. The recommendation further revealed documentation residents should not receive an as needed (PRN) psychotropic medication unless the medication is necessary to treat a diagnosed specific condition and are limited to 14 days unless the physician believes it is appropriate to extend the order beyond 14 days and documents the rationale. Review of the Physician's response to this recommendation revealed he disagreed citing continued need. Review of the progress notes for Resident #27 revealed a note on 3/11/2019 documenting per pharmacy recommendations PRN Ativan should be reevaluated due to the medication being a psychotropic and only advised for approximately 14 days. Per the per Nurse Practitioner the recommendation was denied due to the physician extending the medication per his rationale. Review of the Medication Administration Record (MAR) for December through March revealed no dosages administered from December 3, 2018 through March 27, 2019. During an interview with the Director of Nursing on 03/27/19 at 4:35 P.M., she verified Resident #27 had an order for Ativan 0.5 milligrams as needed every six hours with a start date of 12/03/18 and no dosages given from 12/03/18 through 03/27/19. She further verified the pharmacy had recommended a review of the medication with the Physician documenting continued need despite the resident not receiving the medication for the past three months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 5 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and policy review, the facility failed to ensure residents were free from medication errors. This affected one (#49) resident out of three residents observed for medication administration or seven errors out of 31 opportunities or a 22.58 percent (%) medication error rate. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnosis including heart failure, atrial fibrillation, pneumonia, acute kidney failure, hypertension, diabetes, hyperlipidemia, glaucoma, anemia, dysphagia, muscle weakness, insomnia, dementia, depression, aphasia, hypothyroidism, urinary tract infection, cerebral infarction, and ataxia. Review of Discharge Return Anticipated Minimum Data Set, dated [DATE] revealed Resident #49 has severely impaired cognitive skills, requires total dependence with all activities of daily living, and always incontinent of bowel and bladder. An observation on 03/26/19 at 9:48 A.M. with Licensed Practical Nurse (LPN) #156 revealed LPN #156 administered Eliquis 5 milligrams (mg), folic acid 1 mg, Lisinopril 10 mg, Metoprolol 75 mg, fluexine 2.5 mg, Gabapentin 12 milliliters (ml), and vitamin B12 1,000 micrograms by enteral tube (g-tube). During this administration LPN #156 did not flush between each medication, she poured one medication after another to administer. An interview on 03/26/19 at approximately 9:55 A.M. with LPN #156 verified that she did not flush between medications as she administered through Resident #49's g-tube. Review of the Administering Medications through an Enteral Tube (dated 03/2015) revealed: If administering more than once medication, flush with 15 ml (or prescribed amount) warm sterile purified water between medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 6 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 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 medical record review, observation, staff and resident interview, and policy review, the facility failed to use appropriate infection control techniques and procedures while performing fasting blood sugars, and regarding the placement of indwelling urinary (foley) catheters collection bags. This affected one (#34) out of three residents observed during medication pass and one (#19) out of two residents reviewed for urinary catheters. This had the potential to affect four Residents (#6, #21, #34, & #114) identified by facility as needing fasting blood sugars and the facility identified two Residents (#6, & #19) with catheters on the unit. The facility census was 62. Residents Affected - Few Findings include: 1. An observation on 03/27/19 at 8:27 A.M. revealed Licensed Practical Nurse (LPN) #140 performed a fasting blood sugar on Resident #34. After LPN #140 performed the blood sugar check on Resident #34 she placed glucometer on the medication cart. At 8:50 A.M. LPN #140 placed the glucometer in the medication cart without cleaning/disinfecting the device. Additionally, after pricking the Resident #34's finger [NAME] #140 deposited the lancet into the trash bag. An interview on 03/27/19 at 8:50 A.M. with LPN #140 verified she placed the glucometer in cart and had forgotten to clean/disinfect the device. Interview on 03/27/19 at 11:23 A.M. with Unit Manager #133 and LPN #140 verified that LPN #140 threw the used lancet into the garbage and not the sharps container. Observation on 03/27/18 at 11:24 A.M. of medication cart A on the second floor revealed a used lancet in the open garbage container on the side of the cart. Interview on 03/27/19 at 11:24 A.M. with LPN #140 verified there was an used lancet on the top of the garbage container on the side of medication cart A on the second floor. The facility confirmed this had the potential to affect four Residents (#6, #21, #34, & #114) who receive blood sugar checks. Review of Obtaining a Finger stick Glucose Level Policy (dated 10/2011) revealed to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice, and to dispose of the lancet in the sharps disposal container. 2. Review of the medical record for the Resident #19, revealed an admission date of 05/16/18. Diagnoses included but not limited to urinary tract infection, cellulitis, hypertension, major depressive disorder, symbolic dysfunctions, osteoarthritis, methicillin-resistant staphylococcus aureus (MRSA), cataract and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/11/19, revealed the resident was cognitively intact and the Brief Inventory of Mental Status (BIMS) score was 15. Resident required extensive assistance for bed mobility, transfer, walking, toileting and personally hygiene. Resident required limited assistance for dressing and supervision for locomotion. MDS indicated resident had an indwelling catheter and was incontinent to bowel. Observation on 03/27/19 at 10:00 A.M., revealed Resident #19 lying in bed watching television with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 7 of 8 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 365978 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scarlet Oaks Nursing and Rehabilitation Center 440 Lafayette Avenue Cincinnati, OH 45220 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 the bag to his indwelling catheter lying on the floor under his bed. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #19 on 03/27/19 at 10:01 A.M., stated he has been in bed all night and hasn't gotten out of bed this morning. Residents Affected - Few Interview with Director of Nursing (DON) on 03/27/19 at 10:22 A.M., verified the urinary catheter bag was lying on the floor. DON noted the catheter bag should be inside the bag designed for catheter bags on the side of residents bed. Review of facilities policy titled Policies and Practices - Infection Control dated July 2014, revealed the facilities infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365978 If continuation sheet Page 8 of 8