Inspection·September 28, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's code status was accurately documented. This affected one resident (#13) out of one resident reviewed for advanced directives. The facility census was 58. Findings include: Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, insomnia, chronic fatigue, chronic atrial fibrillation, anxiety disorder, severe protein calorie malnutrition, dysphasia, and history of coronavirus 2019 (COVID-19), Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Review of the physician orders for Resident #13 revealed an order dated 12/16/19 and discontinued 12/19/19, Do Not Resuscitate Comfort Care (DNRCC). An order dated 12/19/19 and discontinued on 04/02/21 revealed a code status of DNRCC. Further review of the physician orders revealed an order dated 04/02/21 and discontinued on 09/20/22 DNRCC-Arrest (A). An order dated 09/20/22 revealed the code status as DNRCC (Comfort Care). Review of Resident #13's medication administration record (MAR) diagnosis list revealed Resident # 13's advanced directives was listed as DNRCC (Comfort Care) and the DNRCC-A was listed with the following information (DNRCC-A discontinued as of 09/20/2022 at 7:21 A.M.) during the time of survey. Review of the progress notes for Resident #13 revealed no information regarding request to change the code status on 12/19/19, 04/02/21, or on 09/20/22. Interview on 09/20/22 at 4:11 P.M., with the Licensed Practical Nurse (LPN) #270 confirmed the Advance Directive order was changed on 09/20/22 to a DNRCC (comfort care). LPN #270 confirmed the prior order in place for Resident #13 was a DNRCC-A which was the incorrect code status. Interview on 09/26/22 at 2:23 P.M., with the Director of Nursing (DON) verified the code status order was changed on 04/02/21 and the facility was not aware of why it was changed. The DON stated the facility identified the wrong order was in place on 09/20/22. Review of the facility policy titled Advanced Directives-Ohio DNR-Form and Policy, dated 08/2016 revealed once the form is completed, the admitting nurse or charge nurse shall obtain a physician's order indicating DNRCC or DNRCC-Arrest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 2 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff, resident, and resident representative interview, and policy review, the facility failed to ensure a safe, clean, and comfortable environment. This affected three residents (#21, #27, and #220) out of three residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included Arnold Chiari Syndrome, hydrocephalus, encephalopathy, presence of cerebrospinal fluid drainage, dysphagia dysphonia, seizures, moderate protein calorie malnutrition, pressure ulcer of sacral region, chronic obstructive pulmonary disease, and hemiplegia. Review of the quarterly [NAME] data set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. The resident was totally dependent on staff with transfers, eating and toilet use. Resident #21 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Interview on 09/19/22 at 11:58 A.M., with Resident #21's representative revealed he has observed Resident #21's wheelchair cushion to be dirty and soiled. The resident representative lifted up the wheelchair cushion and it was visibly soiled with a cracked brown dried substance. Interview on 09/19/22 at 12:17 P.M., with the Licensed Practical Nurse (LPN) #270 verified the cracked, dry, brown substance was on Resident #21's wheelchair cushion. LPN #270 stated the night state tested nurse aides are assigned cleaning the wheelchairs and cushion during the third shift. Review of the facility policy titled Wheelchair - Broda Chair - Gerichair Policy, dated 12/12 stated Wheelchairs and Geri-chairs are cleaned weekly and prn (as needed). 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, austro-esophageal reflux disease, acquired absence of right leg below the knee, major depressive disorder, insomnia, Parkinson's Disease, and hyperlipidemia. Review of the annual MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. The resident was totally dependent on staff with transfers. She required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toilet use. Resident #27 was independent with eating and able to feed herself. Observation on 09/20/22 at 11:45 A.M., revealed Resident #27's floor had food containers, napkins, straw covers, and various trash under her bed and around her trash can. The carpet appeared soiled with debris. Observation on 09/21/22 at 12:13 P.M. Resident #27 was lying in bed with various trash all over the carpet including napkins, straw covers, and food containers. The carpet appeared soiled with debris strewn about. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 3 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/21/22 at 12:16 P.M., with the Registered Dietician (RD) # 500 who verified the trash and debris were strewn across Resident #27's room. RD #500 verified the empty food containers under Resident #27's bed and the large stains on the carpet. 3. Review of the medical record for Resident #220 revealed an admission date of 09/08/22. Diagnosis included perforation of intestine, peritoneal abscess, gastroesophageal reflux disease, and intestines obstruction. Review of the MDS dated [DATE] revealed that Resident #220 was unfinished due to the recent admission. Resident #220 used a walker to ambulate at the facility. Review of the plan of care dated on 09/08/22 revealed Resident #220 was at risk for activity of daily living self-care performance deficit related to impaired mobility and pain. Interventions included assistance required for dressing, bathing, and transfers. Observation and interview on 09/19/22 at 2:04 P.M. with Resident #220 said she had taken a shower earlier in the day to leave the facility. There were towels on the floor in her way which made it difficult to ambulate with the walker. Observation on 09/19/22 at 2:05 P.M. Resident #220 had two-bathroom towels thrown on the floor in the middle of the bathroom near the shower floor. There was trash spilling out of the can. Used paper towels were near the trash can and a used plastic gloves laying near the bathroom trash can. Review of the facility policy titled Environmental Services Nurse's Department, undated revealed It is the policy of this skilled nursing facility to provide guidelines specific for cleaning duties to provide an optimum environment for the staff, residents, and visitors. Resident's rooms are cleaned on a weekly basis. Review of policy titled Management of Soiled Linen revised date 11/2017 revealed place soiled linen, linen with blood or body fluids into designated containers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 4 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the bed hold form, the facility failed to provide notification of the facility's bed hold policy. This affected one resident (#09) out of one resident reviewed. The facility census was 58. Findings include Review of the medical record revealed Resident #09 was admitted on [DATE]. Diagnoses included displaced trimalleolar fracture of right lower leg, major depressive disorder, generalized muscle weakness, anxiety disorder, dysphagia, depression, essential primary hypertension, and fibromyalgia. Review of the discharge with return anticipated minimum data set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. The resident required supervision from staff with transfers, personal hygiene, toilet use, and bed mobility. Review of Resident #09's progress notes revealed she was transferred to the hospital on [DATE] following a fall at the facility. Resident #09 was readmitted to the facility on [DATE] following her hospital stay. Interview on 09/22/22 at 8:45 A.M., with the Administrator provided a paper titled Bed Holds & Leaves of Absence, dated 2018. The Administrator stated this letter was given to each individual when they discharged from the facility to the hospital. Review of the form titled Bed Holds & Leaves of Absence, dated 2018 revealed the letter contained no information regarding the number of bed hold days available or the cost of holding a bed if days were not available. A follow-up interview on 09/22/22 at 10:10 A.M., with the Administrator verified the facility provided each resident a copy of the bed hold policy at the time of discharge. The Administrator said the bed hold notification was a copy of a letter that was given to every resident at discharge. The letter had no specific information for the resident that discharged . The Administrator verified the letter does not provide information regarding the number of bed hold days available or cost of holding a bed if bed hold days were not available. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 5 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review, the facility failed to submit an updated Pre-admission Screenings and Resident Review (PASARR) following the addition of psychiatric diagnosis. This affected two Residents (#27, #35) out of two residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, austro-esophageal reflux disease, acquired absence of right leg below the knee, major depressive disorder, insomnia, Parkinson's Disease, and hyperlipidemia. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. The resident was totally dependent on staff with transfers. She required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toilet use. Review of the PASARR provided by the facility for Resident #27 dated 09/12/17 (resident transferred from another nursing facility), revealed no psychiatric diagnosis was listed under section D. Review of Resident #27 diagnosis list revealed the following diagnoses were added to Resident #27's major depressive disorder was added on 07/03/20, anxiety disorder added on 07/18/20, and post-traumatic stress disorder was added on 07/03/20. 2. Review of the medical record Resident #35 revealed an admission date of 12/15/20. Diagnoses included schizoaffective disorder, partial intestinal obstruction, pancytopenia, hypertension, gastro-esophageal reflux disease, schizoaffective disorder, major depressive disorder, malignant neoplasm of bronchus, and acute kidney failure. Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 had mildly impaired cognition. Resident #35 was independent with bed mobility, dressing, transfers, eating, personal hygiene and toilet use. Review of Resident #35's diagnosis list revealed the diagnoses of schizoaffective disorder was added on 04/27/21, and major depressive disorder, recurrent was added on 12/04/20 with an effective date of 11/19/20. Review of Resident #35's PASARR dated 11/14/20 revealed Section D was marked as no indication of mental health disorders. Review of the facility policy titled PASARR (MI/MR) Identification Screen (OHIO), undated revealed any resident review that requires further evaluation will automatically be referred to the appropriate state agency the [NAME] 2.0 system. Once the determination is made by the state agency. They will send the results directly to the submitter. This will also be uploaded to the electronic health record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 6 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and observation, the facility failed to provide a base line plan of care to the resident or the resident representative within the required timeframe. This affected one resident (#61) out of three reviewed for plan of care. The facility census was 58. Findings include: Review of the medical record for Resident #61 revealed an admission date on 05/19/22. Diagnoses included acute and chronic respiratory failure, age related osteoporosis with pathological fracture, atrial fib, major depressive disorder, congestive heart failure, constipation, wedge compression, and schizoaffective disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #61 had intact cognition. Resident #61 presented no behaviors during the assessment period. Resident #61 required extensive assistance for bed mobility, transfers, toilet use, and personnel hygiene. Resident #61 was incontinent of bladder and has an ostomy. Resident #61 had a stage three pressure ulcer. Review of the baseline plan of care for Resident #61 dated 05/19/22 revealed the plan of care was started on 05/19/22 and signed as completed on 06/08/22. The plan of care had no information regarding her care or services needed. Review of the progress notes dated 05/19/22 through 09/24/22 for Resident #61 had no documentation a baseline plan of care was provided to the resident or resident representative within the first 48 hours of her stay at the facility. Review of the Long Term Care Conference Summary dated 05/25/22 and locked 06/08/22 for Resident #61 revealed a team conference meeting was held with family, resident, nursing, dietary, social worker and activity director. The document had no evidence the plan of care being provided to the resident or the resident representative. Interview and observation on 09/20/22 at 12:03 P.M., with Resident #61 said she had not received a copy of the plan care from the facility. Resident #61 was dressed for the season and groomed. Interview on 09/22/22 at 2:10 P.M., with the Director of Nursing (DON) said the base line plan of care was initiated on 05/19/22 and signed completed by herself on 06/08/22, the DON verified there was no documentation the facility provided the resident with the document as required. A request for a policy related to the baseline plan of care was made during the annual survey and was not provided for review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 7 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0675 Honor each resident's preferences, choices, values and beliefs. 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 ensure call lights were within reach of the resident. This affected three residents (#17, #32, and #41) out of three residents reviewed for call light placement. The facility census was 58. Residents Affected - Few Findings include: 1. Medical record review for Resident #41 revealed an admission date of 03/13/22. Diagnoses included respiratory failure, stroke, hypertension, and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had impaired cognition. Resident #41 required total assistance for bed mobility, transfers, and toilet use. Resident #41 required extensive assistance with eating. Review of the plan of care for Resident #41 dated 09/15/22 revealed the resident was at risk for self care deficits related to chronic obstructive pulmonary disease and dementia. She was alert and not consistent with making her needs known to staff. She received staff assistance with daily care needs. She was encouraged to use the call light for staff assistance with her activities of daily living. Interventions included activities of daily living varies and staff provided care accordingly, resident was non ambulatory and required staff assistance for mobility. Assist with activities of daily living but promote independence. Review of the plan of care for Resident #41 dated 09/15/22 revealed the resident has a diagnosis of chronic obstructive pulmonary disease and stroke. She was alert with confusion. She had no recent falls and was still able to use the call light at times. Interventions included appropriate footwear, clear pathways, check frequently, frequent reminders, teach to lock wheelchair, and remind the resident to use the call light. Observation on 09/19/22 at 12:25 P.M. of Resident #41 resting in bed without the call light within reach. The call light was entangled in the bed frame and the call light activation section was laying on the floor out of the reach of the resident. Interview on 09/19/22 at 12:25 P.M., of Resident #41 verified she was not able to locate her call light. Interview on 09/19/22 on 12:29 P.M., with Licensed Practical Nurse (LPN) #213 verified the resident was able to use her call light and it was not within reach for the resident to activate if needed. LPN #213 verified the call light was on the floor and the clip that attached it to the bed linen was broken and needed replaced. 2. Medical record review for Resident #17 revealed an admission on [DATE]. Diagnoses included hemiplegia and hemiparesis, insomnia, toxic liver disease with hepatitis, atrial fibrillation, depression, diabetes, depressive disorder, heart disease, and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #17 had cognitive impairment. The resident required extensive assistance for bed mobility, dressing, total assistance for transfers and toilet use. Resident #17 was always incontinent of bowel and bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 8 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 0675 Level of Harm - Minimal harm or potential for actual harm Review of the plan of care for Resident #17 dated 09/15/22 revealed Resident #17 was at risk for falls related to balance problems, incontinence, side effects of medications, unaware of safety needs and impaired mobility. Interventions included assist with transfers, mobility, repositioning, and toilet use as needed, may adjust as needs dictate, keep floors free from spills and clutter, adequate light and call light within reach and encourage resident to use while in room, and frequently used items within reach. Residents Affected - Few Observation on 09/19/22 01:34 P.M. revealed resident sitting in her Geri recliner beside her bed and the call light was not available for the resident to use if needed. Interview on 09/19/22 at 1:37 P.M., with LPN #225 verified the call light was not within reach of the resident to use. LPN #225 located the call light in between the wall and the bed on the floor. LPN #225 verified the resident was able to activate the call light system if needed. 3. Review of the medical record for Resident #32 revealed an admission date of 08/03/22. Diagnosis included dementia, major depressive disorder, hallucinations, mild protein calorie malnutrition, and cardiomyopathy. Review of the MDS dated on 08/09/22 revealed Resident #32 was severely cognitively impaired. The resident required extensive two-person assistance for bed mobility, transfers, and toilet use. Resident #32 required one-person physical assistance for personal hygiene, and dressing. Review of the plan of care dated on 08/18/22 revealed Resident #32 was at risk for self-care deficit related to general decline and recent hospitalization. Interventions included assistance with ambulation, bathing, bed mobility, dressing, eating, personal hygiene, oral care, toilet use, and transfers. Observation on 09/19/22 at 1:50 P.M. revealed Resident #32 was alert with periods of confusion. Resident #32 was seated in the recliner with no call light within reach. The call light was approximately three to four feet away from the resident on the bed. Interview and observation on 09/19/22 at 1:51 P.M., with Housekeeper #293 who verified the call light was over on the bed. Housekeeper #293 found the call light near Resident #32's bed and gave it to the resident. Review of the policy titled Nurse Call System, revised date 08/2017 revealed the staff will ensure the call light was within reach when the resident was in their room or bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 9 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff and resident interview, the facility failed to ensure care planned interventions were implemented as ordered. This affected three residents (#01, #17, and #61) out of three residents reviewed for quality of care. The facility census was 58. Residents Affected - Few Findings include 1. Medical record review for Resident #17 revealed an admission on [DATE]. Diagnoses included hemiplegia and hemiparesis, insomnia, toxic liver disease with hepatitis, atrial fibrillation, depression, diabetes, depressive disorder, heart disease, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had cognitive impairment. Resident #17 required extensive assistance for bed mobility, dressing, total assist for transfers and toilet use. Resident #17 was coded with functional impairment on bilateral upper extremities. Review of the plan of care for Resident #17 dated 09/05/22 revealed the resident had an activity of daily living self-care performance deficit related to impaired mobility, stroke, and contracture of the right hand and the right ankle. Interventions included range of motion as tolerated and a splint device to the right hand as tolerated. Review of the physician orders dated 08/19/22 for Resident #17 revealed an order to discontinue occupational evaluation order and resume the splint wearing schedule as before and as posted in the room. The patient was to donn the right resting hand splint after the evening meal, remove at breakfast. Review of the physician orders dated 07/07/22 for Resident #17 revealed an order to place the right resting hand splint on at night and off during day. Interview on 09/19/22 1:52 P.M., with Resident #17 stated she had a contracture on her right hand due to a stroke and the staff was supposed to put a splint on but they had not placed the splint in a long time. Observation on 09/20/22 6:50 P.M. of Resident #17 revealed no splint in place at this time. Observation on 09/22/22 at 7:01 A.M. of Resident #17 revealed no splint in place as ordered. A follow-up interview on 09/20/22 at 7:01 A.M., with Resident #17 stated the staff had not put the splint on last night. Interview on 09/22/22 at 7:03 A.M. with Licensed Practical Nurse (LPN) #233 verified the splint was not in place as it should have been. LPN #233 verified they were going to have to look for the splint as it could not be located at the time of the interview. A request for a policy related to the application of splinting devices was requested during the survey and not provided for review. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 10 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Medical record review for Resident #61 revealed an admission date on 05/19/22. Diagnoses included acute and chronic respiratory failure, age related osteoporosis with pathological fracture, atrial fibrillation, major depressive disorder, congestive heart failure, constipation, wedge compression, schizoaffective disorder. Review of the quarterly MDS dated [DATE] revealed Resident #61 had intact cognition. Resident #61 was not assessed with behaviors. Resident #61 required extensive assistance for bed mobility, transfers, toilet use, and personnel hygiene. Review of the plan of care for Resident #61 dated 09/15/22 revealed Resident #61 was at risk for bleeding related to aspirin therapy and anticoagulant. Interventions included administer medication as ordered, gently provide oral hygiene, monitor for signs and symptoms of bleeding and obtain laboratory tests as indicated. Review of the active physician orders for Resident #61 revealed an order dated 05/19/22 for Eliquis five milligrams give one tablet two times a day for atrial fibrillation, an order dated 05/20/22 for monitoring bruises for healing, and an order dated 05/19/22 stating resident was on blood thinners, observe for signs and symptoms of bleeding and report to the physician. Review of the admission skin assessment dated [DATE] for Resident #61 revealed five areas of bruising on the left lower leg measuring 5.5 centimeters (cm) by 2.5 centimeters, right hand measuring 10.5 cm by 6.5 cm, right lower leg measuring 7.5 cm by 4 cm, left hand measuring 2.5 cm by 2.0 cm, and a right antecubital bruise measuring 2.5 cm by 2.0 cm. Review of the Nurse practitioner (NP) progress note dated 08/10/22 revealed no documentation of any bruising on the residents arms and hands. Review of the progress notes for Resident #61 dated 05/19/22 through 09/24/22 revealed no documentation of any bruising or physician notification. Review of the current electronic health record assessment tab for Resident #61 revealed no documentation of any measurements or monitoring of bruising. Review of the previous electronic health record assessment tab for Resident #61 revealed no documentation for any measurements or monitoring of bruising. Observation on 09/20/22 at 12:03 P.M. of Resident #61 sitting in the activity room. Bruising noted to both arms covering the majority of the lower forearms and hands. Bruises were deep purple in color and in various stages of healing. Interview on 09/20/22 at 12:03 P.M., with Resident #61 stated she has new bruises all the time related to her medication, one will heal and then another one will show up. Resident #61 stated staff had not measured them. Resident #61 verified that no one had abused her causing the bruises. Interview on 09/22/22 at 1:19 P.M., with the Director of Nursing (DON) said she spoke with the resident about the new bruising on her hand and was told by the resident that she hit her arm on the table when she was bringing her arm from her lap to the table. The DON verified no measurements were documented in the resident's medical record, the physician was not notified, and it was not measured. The DON said when a new skin issue was identified the staff would measure the area and notify the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 11 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm physician. Additionally, stated since we know the resident was on a blood thinner bruises were to be expected and they were not identified as injuries of unknown origin. A policy regarding anticoagulant monitoring was requested on 09/21/22 and 09/22/22 and not provided for review. Residents Affected - Few 3. Review of the medical record for Resident #01 revealed an admission date of 12/21/2021. Diagnosis included cerebrovascular disease, non-Hodgkin lymphoma, non-pressure chronic ulcer of left ankle, atrial fibrillation, and disorientation. Review of the MDS assessment dated [DATE] revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Review of the plan of care dated on 09/02/22 revealed Resident #01 was at risk for falls related to a recent diagnosis of transient ischemic attacks (TIA) with facial drooping. Resident #01 was currently non-ambulatory and used a wheelchair for mobility. Interventions included air mattress with bolsters, appropriate clothing and foot wear, frequent reminders, remind to use the call light, frequent repositioning, avoid laying at edge of bed, encourage to use call light, and check frequently. Review of the interdisciplinary team (IDT) follow up note on 08/23/22 at 8:36 A.M. revealed Resident #01 had a skin tear to the left upper extremity. The resident had a bruise on the left arm and had thin skin. A skin tear was received during morning care when staff was turning the resident in bed. A new interventions of geri sleeves was added to help prevent further skin tears and bruising to his upper extremities. Review of the physician order dated 08/24/22 for Resident #01 revealed geri sleeves every shift on both arms for protection of the skin. Observation on 09/20/22 at 5:07 P.M. Resident #01 was lying in bed, awake and had no geri sleeves on. Interview on 09/20/22 at 5:15 P.M., with LPN #500 who verified Resident #01 had no geri sleeves on at the time. Observation on 09/21/22 at 10:10 A.M. Resident #01 was lying down in bed and had no geri sleeves on at the time. Interview on 09/21/22 at 10:12 A.M., with the Assistant Director of Nursing (ADON) #229 who stated Resident #01 should have had his geri sleeves on his arms. The ADON #229 said she had put them on last night before she left. Observation on 09/21/22 at 10:14 A.M. with the ADON #229 who picked up the geri sleeves laying in the chair and placed the geri sleeves on Resident #01. Interview on 09/27/22 at 6:00 P.M., with the Administrator who said they had no skin protection policy or skin protocol at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 12 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as ordered. This affected one resident (#01) out of three residents reviewed. The facility census was 58. Findings Include: Review of the medical record for Resident #01 revealed an admission date of 12/21/21. Diagnosis included cerebrovascular disease, non-Hodgkin lymphoma, non-pressure chronic ulcer of the left ankle, atrial fibrillation, and disorientation. Review of the minimum data set (MDS) assessment dated on 08/28/22 revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Review of the plan of care dated on 09/02/22 revealed Resident #01 was at risk for falls related to transient ischemic attacks (TIA), and a history of atrial fibrillation. Resident #01 was non-ambulatory but used a wheelchair. Interventions included an air mattress with bolsters, appropriate footwear, check frequently, extra low bed and to keep the bed in a low position, fall mats to both sides of the bed, provide frequent positioning, and avoid laying on the edge of the bed. Observation on 09/20/22 at 5:07 P.M. revealed Resident #01 was awake in his bed, there was no bolster located on the bed. There was only one fall mat next to the right side of the right side of the resident, but did not have a fall mat located on Resident #01's left side the side not by the wall. Interview on 09/20/22 at 5:15 P.M., with the Licensed Practical Nurse (LPN) #500 verified Resident #01 had no fall mat to the left side, and had no bolsters on his air mattress for fall prevention. Observation on 09/21/22 at 10:10 A.M., revealed Resident #01 was lying down in his room in bed and the fall mat to his left side was not laid down on the floor. Resident #01 had no bolsters on the air mattress. Interview on 09/21/22 at 10:12 A.M., with the Assistant Director of Nursing (ADON) #229 said hospice was supposed to bring a bolster for Resident #01's bed and had not brought one in. Review of policy titled Fall and Fall Risk Managing, revised date 08/2017 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to decrease the resident risk from failing and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 13 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **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 ensure medications were safely stored. This affected three residents (#47, #26, and #48) out of seven residents reviewed for medication storage. The facility census was 58. Findings include: 1. Medical record review for Resident #47 revealed an admission date of 02/17/22. Diagnoses included chronic kidney disease, ischemic cardiomyopathy, falls, anemia, heart failure, and bullous pemphigoid (a rare skin condition causing large, fluid filled blisters). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition. Resident #47 required extensive assistance for bed mobility and toilet use. Observation on 09/19/22 at 8:15 A.M. revealed Resident #47 was resting in bed watching television. A tube of diphenhydramine cream two percent (%) was located on the bedside table. The tube was labeled with a prescription for use for Resident #47. Interview on 09/19/22 at 9:15 A.M., Resident #47 stated she received the cream four times a day for a rash she had and they must have left it in her room. Interview on 09/19/22 at 9:22 A.M. with the Licensed Practical Nurse (LPN) #225 verified the cream was for Resident #47 and should not have been left in the resident's room. 2. Medical record review for Resident #48 revealed an admission date of 05/28/21. Diagnoses included type two diabetes, hypertension, falls, and depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 required extensive assistance for bed mobility. The resident was totally dependent for transfers, eating and toilet use. Observation on 09/19/22 at 8:15 A.M. revealed Resident #48 resting in her bed. On the bedside table was a thirty-millimeter medication cup filled to the top with a white creamy substance. Interview on 09/19/22 at 9:22 P.M., with the LPN #225 verified the white lotion without a label on Resident #48's bedside stand. LPN #225 said the resident received Voltaren Gel one percent to her shoulders, elbow and hand every eight hours for arthritis pain but LPN #225 could not confirm what the substance was in the medication cup but it should not be in a resident's room. 3. Medical record review for Resident #26 revealed an admission date of 05/26/22. Diagnoses included ileus, heart failure, cellulitis, tachycardia, acute kidney failure, hypertension, peripheral vascular disease, urinary retention, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required extensive assistance for bed mobility and transfers. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 14 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 #26 required total assistance for toilet use and supervision for eating. Level of Harm - Minimal harm or potential for actual harm Observation on 09/20/22 10:54 A.M. revealed Resident #26 was resting in bed with his bedside table positioned across the front of the resident. On the bedside table in a pharmacy labeled bag was a bottle of artificial eye drops 1.4 percent with the resident's name on it. Residents Affected - Few Interview on 09/20/22 at 10:54 A.M., Resident #26 stated the nurse brought the eye drops in this morning and forgot to take them out with her. Interview on 09/20/22 at 11:05 A.M., with LPN #287 verified the eye drops were for Resident #26 and should not have been left in the room unsecured and unattended. Review of facility policy titled Medication Storage, dated 12/21 revealed medication and biological's, including treatment items are securely stored in a locked cabinet that is inaccessible by residents and visitors. This deficiency substantiates Master Complaint Number OH00135948. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 15 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 interview, and policy review, the facility failed to ensure resident medications were handled in a sanitary manner to decrease the potential of infection. This affected one resident (#19) out of four residents observed for medication administration. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 2/21/22. Diagnoses included type two diabetes, dementia with behavioral disturbances, hypertension, chronic kidney disease, anxiety disorder, congestive heart failure, and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had impaired cognition. Review of the active physicians orders for Resident #19 revealed orders for Flonase suspension 50 micrograms (mcg) spray both nostrils one time a day for allergies, azelastine (an antihistamine) solution 137 mcg one spray in each nostrils every 12 hours, MiraLax (a laxative) packet 17 grams (gm) one packet daily, metoprolol succinate extended release 25 milligrams (mg) one tablet every day for hypertension, magnesium oxide (a supplement) 400 mg one tablet daily, ferrous sulfate (iron supplement) 325 mg one tablet daily, multivitamin one tablet daily, sertraline (an antidepressant) 25 mg one tablet daily, aspirin chewable 81 milligrams daily, Lasix (a diuretic) 40 mg tablet daily, omeprazole (a medication to treat heartburn or reflux disease) 20 mg one tablet daily, buspirone (an anxiolytic medication) 10 mg one tablet daily, tamsulosin (urinary retention medication) 0.4 capsule one daily, senna plus (a medication for constipation) 8.6-50 one tablet one time a day, and cetirizine (antihistamine) 10 mg one tablet one time a day. Observation on 09/22/22 at 8:54 A.M. Licensed Practical Nurse (LPN) #225 prepared medications for Resident #19. Prior to the preparation LPN #225 had not performed any hand hygiene before removing the Flonase suspension, azelastine solution, MiraLax packet, metoprolol succinate extended release, magnesium oxide, ferrous sulfate, multivitamin, sertraline, aspirin, Lasix, omeprazole, buspirone, tamsulosin, senna plus, and cetirizine from the medication cart. LPN #225 handled the medication cart keys, the medication cart drawers, and touched the individual medication boxes for each medication. LPN #225 used scissors to open the MiraLax package and poured water from a water pitcher on the cart into a cup then emptied the MiraLax package into the cup and stirred it with a spoon. LPN #225 tore open each individual package emptying the pill into the medication cup. While emptying the package for magnesium oxide the pill fell onto the medication cart surface. LPN #225 picked up the pill with her bare hands and placed the pill into the medication administration cup with the other opened medications. LPN #225 then picked up the last remaining packet and placed the packet into the medication cup with the other opened medication, advising the surveyor she needed to take the blood pressure before administering the medication. LPN #225 then administered medication to Resident #19 after taking the blood pressure and opening the last remaining individual medication package and emptying it into the medication administration cup with the other medications. Interview on 09/22/22 at 9:05 A.M., with LPN #225 verified she picked up the pill when it spilled onto the medication cart top surface using her bare hands and placed it into the medication cup with the other opened medication and had not performed hand hygiene prior to picking up the medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 16 of 17 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 366040 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011 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 - Few with her bare hands. LPN #225 verified she placed the metoprolol still in the package from the pharmacy into the medication administration cup touching other opened capsules and pills, and carried them into the room for administration to the resident. Interview on 09/23/22 at 4:09 P.M., with the Director of Nursing (DON) via electronic message verified medication should not be handled with bare hands and administered to a resident. Review of the facility policy titled Administration Oral Medications, dated 12/2021 revealed tablets and capsules are handled so that fingers do not touch them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 17 of 17