Inspection·June 27, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few vertebra, sacral, and sacrococcygeal region until 07/03/25.Review of Resident #41's June 2025 medication administration record (MAR) revealed evidence to indicate staff changed the resident's IV tubing and PICC dressing and needleless connector on 06/22/25. The MAR further revealed evidence to indicate staff changed the resident's IV tubing on 06/23/25 and 06/24/25.Review of Resident #41's June 2025 treatment administration record (TAR) revealed evidence to indicate staff cleansed the skin tear to the right forearm with normal saline, applied gauze, and covered the area with retention tape on 06/23/25 and 06/24/25.During an observation on 06/23/25 at 9:27 A.M., Resident #41 was in bed and an undated dressing was observed on the resident's forearm. An IV was observed in the resident's upper right arm, also with an undated dressing. During an observation on 06/24/25 at 3:15 P.M., Resident #41 was in bed with a dressing on the resident's right forearm, with no date or initials. The resident's IV was running, and no date was observed on the IV dressing or tubing.During an interview on 06/24/25 at 3:26 P.M., Licensed Practical Nurse (LPN) #24 stated they changed IV dressings every Sunday. She stated there should be a date on Resident #41's dressings and the IV tubing.During an interview on 06/24/25 at 3:33 P.M., LPN #24 went into Resident #41's room to check the IV tubing and associated dressing, as well as the dressing on Resident #41's forearm. At 3:34 P.M., LPN #24 exited Resident #41's room and confirmed there was no date on the resident's IV dressing or tubing, nor was the dressing on Resident #41's forearm dated.During an interview on 06/25/25 at 12:01 P.M., LPN #22 stated the treatment for Resident #41's dressings should have been initialed and dated.During an interview on 06/25/25 at 1:43 P.M., Registered Nurse (RN) #12 stated IV lines should be dated and were changed every 24 hours, noting she was fairly certain that was the facility policy.During an interview on 06/25/25 at 2:13 P.M., LPN #23 confirmed she completed the treatment dressing for Resident #41 on 06/24/25. LPN #23 stated that when a dressing was changed, the nurse was to put their initials and date on the dressing.During an interview on 06/27/25 at 11:18 A.M., the Assistant Director of Nursing (ADON) stated the wound care nurse conducted routine checks daily to ensure the dressings were done daily, and she checked behind the wound care nurse and made sure everyone was checked daily. She stated she walked into the resident rooms, and she was not aware of the dressings and tubing not being dated until it was presented. She stated she did not have a set time to conduct these checks, noting it was sporadic. She stated anyone who was setting up or administering the IV tubing and dressing and the dressings should initial and date them.During an interview on 06/27/25 at 11:33 A.M., the Director of Nursing (DON) stated her expectation was for nurses to date Resident #41's IV dressing and tubing on their shift and should date and initial the dressing for the forearm if they performed the treatment. She stated they had numerous resources and corporate educators if staff had a question related to professional standards of practice.During an interview on 06/27/25 at 11:55 A.M., the Administrator stated her expectation was for staff to date all dressings and tubing at some point during the shift, ideally at the time of the tubing and dressing change, but at least prior to end of the shift.During an interview on 06/27/25 at 3:10 P.M., RN #25, a regional educator, stated for nurse competencies they pulled the policy and step-by-step instructions and completed the competencies according to the policy. RN #25 stated that it included dating dressings for treatments and IVs.Review of a facility policy titled, Quality of Care - Care Planning, dated 10/2022, revealed, each discipline is responsible for implementing and providing input (based on patient/resident representative feedback) on any interventions to assist the patient in achieving their goals and desired outcomes. The policy revealed the facility must monitor effects of their approaches to ensure they are implemented as intended and have the desired effect to achieve measurable objectives and resident's goals for care.Review of a facility policy titled, Infection Control Dressings, Dry/Clean, revised in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 2 of 10 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 06/27/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 08/2024, revealed, the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. The policy noted that steps in the procedure included for staff to have available strips of tape adequate for securing dressing at the end of the procedure and add date, time and initials.Review of a facility policy titled, Venous Access Devices: Midline Catheters, revised in 08/2016, revealed a midline catheter is meant to provide a passage to introduce prescribed fluids or IV medication directly into the basilic, cephalic, or brachial vein distal to the shoulder. Dressings should be changed weekly and if the integrity of the dressing is compromised unless ordered sooner by Physician/clinician. The policy continued for staff to label the dressing with date/time and nurses initials.Review of a facility policy titled, Venous Access Devices: Peripheral IV Lines, dated 01/2018, revealed, a peripheral IV line is meant to provide a passage to introduce prescribed fluids or IV medication directly into the veins. The policy did not address IV dressing changes or the insertion of an IV. Event ID: Facility ID: 366040 If continuation sheet Page 3 of 10 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 06/27/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to ensure that dented cans were removed from the dry storage area in the kitchen. This had the potential to affect all 83 residents residing in the facility. The census was 83.Findings include:Observations of the kitchen dry storage area on 06/23/25 at 10:04 A.M. with the Chef revealed 13 dented cans amongst the canned goods. The dented cans included two (2) seven-pound (lb.) cans of pudding, 2 five lb. cans of spinach, eight (8) six lb. cans of peaches, and one (1) seven lb. can of refried beans. During an interview on 06/23/25 at 10:06 A.M., the Chef stated she and the cooks put the canned food deliveries away. She stated [NAME] #2 stocked the canned peaches the prior Monday. She stated dented cans should be removed from the dry storage and placed in her office so she could submit them for credit and confirmed the dented cans. She stated botulism bacteria could get into the canned food if the dent caused a hole or broke the seal. She stated the dented canned food found should have been removed and returned for credit. She stated she checked the can rack and canned goods and missed the dented cans. She stated the canned goods were received during multiple deliveries. During an interview on 06/25/25 at 10:28 A.M., [NAME] #1 stated she had been with the facility for 16 years. She stated she helped put away orders and checked the canned goods for dents as she put them away. She stated dented cans were stored in the Chef's office and the Chef coordinated replacement canned goods. She stated she did not put away the dented cans of peaches from the prior week's order. She stated dented cans were dangerous because the dent could allow bacteria and germs into the canned food, causing foodborne illness. She stated she always checked for dented cans to protect the residents. On 06/26/25 at 11:43 A.M. and on 06/27/25 at 8:29 A.M., a telephone interview was attempted with [NAME] #2 with no answer received. During an interview on 06/26/25 at 7:24 A.M., [NAME] #3 stated she had worked at the facility for 20 years. She stated she helped stock orders in the dry storage area. She stated canned goods should be screened for dents and, if found, removed from the usable canned food area. She stated the dented cans were put in the Chef's office for credit. She stated dented cans should not be used because they could cause illness to the residents. She stated she did not help stock the last order that was received. She stated the Chef was responsible for checking and screening the canned goods. During an interview on 06/26/25 at 3:50 P.M., the Regional Chef (RC) stated dented cans should be separated and returned for credit. He stated botulism and other foodborne illness could occur if air entered the canned goods. During an interview on 06/26/25 at 3:51 P.M., the Registered Dietitian (RD) stated that dented cans should be set aside and returned for credit. She stated canned goods should be received and inspected while being put away on the racks. She stated dented cans should be screened because, if the seal was broken, botulism could grow in the canned foods.During an interview on 06/27/25 at 10:08 A.M., the Administrator stated food from dented cans would not be served and canned goods should be reviewed and designated for removal if dented. Review of a facility policy titled, Receiving, revised in 06/2015, indicated, the facility will ensure all food items and kitchen supplies purchased are received properly. When a vendor arrives with food, he/she will bring food items and kitchen supplies to the main kitchen and places items in the dry storage room or walk-in. The food will be received by a cook, the dietary manager or designee. After receiving, one of the above personnel will check in the food items and make sure all items ordered are accounted for. If an item is missing, the driver/vendor will be asked to deduct the item from the bill. If an item is of poor quality, it can be refused, and the items should be deducted from the bill. Event ID: Facility ID: 366040 If continuation sheet Page 4 of 10 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 06/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview, the facility failed to ensure wound care was documented accurately for one (#82) of three residents sampled for pressure ulcers. The census was 83. Findings include:Review of Resident #82's medical record revealed an admission date of 02/05/25. Diagnoses included multiple sclerosis, morbid obesity, hyperlipidemia, major depressive disorder, anxiety disorder, restless leg syndrome, essential hypertension, pulmonary embolism, constipation, neurogenic bowel, and neuromuscular dysfunction of the bladder. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/11/25, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS assessment indicated the resident was dependent on staff for toileting hygiene, rolling left to right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and to walk 10 feet. The MDS assessment further indicated that the resident had an indwelling catheter, was always incontinent of bowel, had a stage II pressure ulcer (partial-thickness skin loss involving the dermis), and an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) present on admission. Review of Resident #82's care plan report included a focus area, dated 02/05/225, that indicated the resident had a pressure ulcer/injury to the coccyx and right heel and was at risk for new development, worsening, recurrence related to community acquire, decreased functional ability, decreased sensory mobility, history of pressure ulcer/injury, history of skin breakdown, hypertension, impaired/decreased mobility, major depressive disorder, anxiety, hyperlipidemia incontinence, slow healing expected per wound nurse practitioner, and history of complicated wounds with a need for frequent debridement. Interventions directed staff to administer medications as ordered, administer nutritional interventions as ordered, administer treatments as ordered and monitor for effectiveness, assist as needed with mobility, turning and repositioning, assist as needed with toileting and hygiene, consult wound nurse practitioner, provide a particular wheelchair cushion, document non-compliance, and evaluate wound for size and depth. Interventions also directed staff to document progress on an ongoing basis, notify physician as indicated, provide an indwelling urinary catheter, provide a house supplement per physician orders, keep resident/responsible party updated on status, monitor for non-compliance, educate about risk with noncompliance, and monitor for signs of pain/discomfort. Administer pain medications and other interventions as needed, monitor for signs and symptoms of infections, monitor need for isolation precautions, notify clinician of worsening conditions, and obtain and monitor laboratory values/diagnostic tests as ordered. Review of Resident #82's February 2025 treatment administration record (TAR) revealed an order entry for Dakins (sodium hypochlorite 1/4 strength) external solution to be applied to the coccyx topically every day and night shift with a start date 02/19/25 and end date 03/06/25. The TAR revealed no evidence to indicate the treatment was completed on 02/25/25 for the day shift. The TAR also revealed an order entry for Dakin's external solution to be applied to right and left buttocks topically each day and night shift with a start date 02/13/25 and an end date of 02/19/25 at 1:22 P.M. The TAR revealed no evidence to indicate the treatment was completed on the evening shift on 02/14/25 and 02/15/25.During an interview on 06/27/25 at 12:42 P.M., Licensed Practical Nurse (LPN) #14 revealed she had been trained to complete treatments and then document their completion. She stated she completed Resident #82's treatments on 02/14/25 and 02/15/25 and must have hurriedly left the building and failed to document their completion. Review of Resident #82's March 2025 TAR revealed Dakin's (1/2 strength) external solution to be applied to the sacrum topically every day and night shift. Directions indicated to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 5 of 10 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 06/27/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete cleanse with Dakin's, pack with Dakin's moistened gauze, cover with abdominal pad (ABD), and secure with retention tape with a start date of 03/06/25 and an end date of 03/21/25 at 12:29 P.M. The TAR revealed no evidence to indicate the treatment was completed on the day shift on 03/07/25. During an interview on 06/27/25 at 10:43 A.M., LPN #13 revealed she had been trained to document when treatments were completed. She stated she performed Resident #82's treatment on 03/07/25 but failed to sign the treatment as completed. Review of Resident #82's April 2025 TAR revealed an order entry for Dakin's (1/2 strength) external solution to be applied to the coccyx topically every day and night shift. Directions indicated to cleanse the wound with Dakin's, pack with Dakin's moistened gauze, cover with ABD, and secure with tape with a start date of 04/03/25 at 7:00 P.M. and an end date of 04/17/25 at 7:05 P.M. The TAR revealed no evidence to indicate the treatment was completed on 04/03/25 on evening shift and 04/14/25 on day shift. During an interview on 06/27/25 at 12:50 P.M., Registered Nurse (RN) #6 revealed she had been trained to document completion after each treatment had been completed; however, she stated she forgot to sign after she completed Resident #82's treatment on 04/03/25 and 04/14/25. During an interview on 06/27/25 at 12:55 P.M., the Director of Nursing (DON) stated she expected wound care for Resident #82 to be completed and documented in the resident's electronic medical record after it was completed.During an interview on 06/27/25 at 1:37 P.M., the Administrator stated she expected wound care for Resident #82 to be completed as ordered and documented in the medical record when completed. This deficiency represents non-compliance identified under Complaint Number OH00165272 (iQIES Complaint Number 1372878). Event ID: Facility ID: 366040 If continuation sheet Page 6 of 10 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 06/27/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and resident representative interview, staff interview, medical record review, facility document and policy review, and review of corrective action documents, the facility failed to execute an effective pest control program for the prevention and control of mice in the facility. This affected four (#5, #12, #13, and #20) of 83 residents residing in the facility. The census was 83. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 11/14/24. Diagnoses included major depressive disorder and adjustment disorder with anxiety.Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated Resident #5 had no potential indicators of psychosis. During a concurrent interview and observation in Resident #5's room on 06/23/25 at 9:29 A.M., Resident #5 stated they saw mice in their room. Resident #5 stated they had been seeing the mice since 10/21/24, and stated a family member had also seen them in Resident #5's room. Resident #5 stated the mice would leave when staff opened the door, and the mice would play with the paper traps the facility placed in Resident #5's room. A large black box was observed in the corner of the room with the name of a pest control company engraved on it. Resident #5 stated the facility brought the black box last week, and mice had been seen in the room since then. Resident #5 stated some of the mice were gray and some were darker gray. Resident #5 added the mice had not torn up any of the belongings in their room, but having mice in their room made the resident feel bad. Small black pellets that appeared to be mouse excrement (feces) were observed in Resident #5's closet on the left side in a corner and on a sticky trap on the right side of the closet floor.During an observation in Resident #5's room on 06/24/25 at 11:28 A.M., a small number of black pellets that appeared to be mouse excrement were observed in the left corners of Resident #5's closet. During an interview with Licensed Practical Nurse (LPN) #13 and observation in Resident #5's room on 06/24/25 at 11:31 A.M., LPN #13 looked in Resident #5's closet and stated that the black pellets looked like mouse droppings. LPN #13 stated she had not seen any mice but had heard people scream when they saw mice. LPN #13 stated she had worked at the facility for a year and a half, and there were mice the entire time. LPN #13 stated the mice had become worse in the last couple of months, and the residents had complained about mice. LPN #13 stated she did not feel like there were any risks to the residents and thought that maintenance and the head of housekeeping were responsible for monitoring for pest control.During an interview on 06/25/25 at 8:39 A.M., Certified Nurse Aide (CNA) #7 stated she had seen two mice about two and a half weeks prior in a resident's room. CNA #7 stated residents on the long term care unit had complained about mice, and maintenance was responsible for monitoring pest control. CNA #7 stated Resident #5 was upset regarding the mice.Review of a pest control company invoice dated 06/25/25 revealed no mice activity was found, and the mouse droppings found in Resident #5's room were hard, dry, and not fresh.2. Review of Resident #20's medical record revealed and admission date of 04/29/21. The resident had a diagnosis of major depressive disorder.Review of a quarterly MDS assessment, with an ARD of 05/13/25, revealed Resident #20 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS assessment indicated Resident #20 had no potential indicators of psychosis. During a concurrent interview and observation in Resident #20's room on 06/23/25 at 10:07 A.M., Resident #20 stated there were mice in the facility but not recently. Resident #20 stated that about three or four weeks prior there was a mouse under the bed. Resident #20 stated they were scared of the mice. A small amount of black pellets that appeared to be mouse excrement were observed behind Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 7 of 10 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 06/27/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #20's refrigerator.3. Review of Resident #13's medical record revealed an admission date of 10/21/23. Diagnoses included major depressive disorder, generalized anxiety disorder, and adjustment disorder with mixed anxiety and depression.Review of a quarterly MDS assessment, with an ARD of 05/22/25, revealed Resident #13 had a BIMS score of two (2), which indicated the resident had severe cognitive impairment. During an observation in Resident #13's room on 06/23/25 at 10:20 A.M., black pellets that appeared to be mouse excrement were observed under Resident #13's bed.During an interview on 06/25/25 at 9:26 A.M., CNA #18 stated she had started seeing mice and mice droppings about a month prior. CNA #18 stated she had seen a mouse under Resident #13's bed during the day the past month. CNA #18 stated the facility had been using sticky mouse traps and snap traps previously, but about a week ago the facility started using big black mouse trap boxes. CNA #18 stated the residents told her they did not like mice running around in their rooms, and the risks to the residents were that the residents could catch a disease. CNA #18 stated maintenance and housekeeping were responsible for monitoring pests in the building. CNA #18 stated she felt like the facility was trying and that the pest control had become more effective.4. Review of Resident #12's medical record revealed an admission date of 12/02/22. The resident had a diagnosis of macular degeneration.Review of a quarterly MDS assessment, with an ARD of 06/06/25, revealed Resident #12 had a BIMS score of four (4), which indicated the resident had severe cognitive impairment. During an interview on 06/25/25 at 1:37 P.M., Power of Attorney (POA) #27 stated they saw a mouse about a month prior, and Resident #12's closet was full of mouse feces. POA #27 stated they had seen mouse droppings in the closet even after they had cleaned it but had not seen any mouse droppings in the last week or week and a half. POA #27 stated Resident #12 did not appear to be bothered by the mice, but Resident #12's roommate was bothered by the mice. POA #27 stated Resident #12's roommate was currently in the hospital, but the roommate had reported the mice had gotten into their snacks.During an observation in the hall of the long-term care (LTC) unit on 06/23/25 at 10:59 A.M., three pest control employees were observed going from room to room checking the black boxes that were labeled with the name of the pest control company. Review of pest control service reports from the prior pest control company, for the timeframe from 04/16/25 through 05/09/25, revealed the facility had one rodent bait station, and there was no evidence of activity. There were no pest control service reports provided for the timeframe from 05/10/25 to 06/18/25.Review of pest control service reports from the current pest control company, for the timeframe from 06/19/25 through 06/25/25, revealed 19 bait stations, 10 tin cat traps (mouse traps), and 54 snap traps (mouse traps) were placed in the building. A service report dated 06/23/25 indicated no pest activity had been found.During an interview on 06/24/25 at 8:45 A.M., Housekeeper #16 stated she was not sure how long there were mice in the facility but thought it had been more than a month. Housekeeper #16 stated she was not sure how long the exterminators had been coming to the facility but noted that the mouse situation had improved.During an interview on 06/25/25 at 9:00 A.M., CNA #17 stated she had seen one or two mice but was not sure when that was. CNA #17 stated she had not seen any mice recently. CNA #17 stated residents had not complained recently, and the pest control had improved in the last month. During an interview on 06/25/25 at 9:49 A.M., the Environment Services Supervisor (ESS) stated the mouse problem had just started suddenly about three to four weeks prior. The ESS stated everyone was responsible for monitoring for mice and should put an order in their maintenance system if any mice or droppings were seen. During an interview on 06/25/25 at 10:58 A.M., the Maintenance Director stated he had worked at the facility for three weeks, and glue traps were being used for pest control at that time. During an interview on 06/25/25 at 11:06 A.M. with the Maintenance Director, Regional Maintenance Coordinator (RMC) #19, and RMC #20, the Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 8 of 10 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 06/27/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Director stated he had checked the mouse traps with the extermination company on 06/23/25, and there were no mice in the traps. RMC #19 stated that three weeks prior the former maintenance director was no longer employed with the facility, and employees told RMC #19 that they had seen mice in the facility. RMC #20 added that all reports of mice came from the LTC unit. RMC #19 stated that when he became aware of mice sightings, he placed glue traps in the residents' closets. RMC #19 stated that he caught two adult mice and some baby mice. RMC #19 stated he always caught two or three mice a year. RMC #19 added that the previous Maintenance Director and previous pest control company did not address the situation correctly. RMC #19 stated the Maintenance Director was responsible for monitoring pest control. During an observation in Resident #5's room on 06/25/25 at 1:27 P.M., the Maintenance Director was observed with a member of the pest control company looking in Resident #5's closet.During an interview on 06/25/25 at 2:09 P.M., the Director of Nursing (DON) stated she had worked in the facility for two months and had never seen any mice or mouse droppings. The DON stated everyone was responsible for monitoring for pests, and the risks to the residents were that they could get an infection. The DON stated her expectation was that if they identified an issue that housekeeping and maintenance would be notified, and the pest control company would come to the facility.During an interview on 06/25/25 at 2:27 P.M., the Regional Administrator (ADM) stated she was the ADM for the facility from November 2023 until March 2025 and was not aware of any pest control issues. The Regional ADM stated a pest control company was coming to the facility twice a month, and she never saw any mice or any mice droppings. The Regional ADM stated a family member for Resident #5 complained in March 2025 or April 2025 about mice, and the facility did a search of Resident #5's room. The Regional ADM stated no one had notified her of any mouse droppings being found. The Regional ADM added that maybe two or three adult mice had been found, and the rest were baby mice. The Regional ADM stated everyone was responsible for monitoring the facility for pests, and there were no risks to the residents unless they ate the mouse droppings. The Regional ADM stated her expectation was to find the issue, treat it, and keep checking.During an interview on 06/25/25 at 3:56 P.M., the ADM stated she began working in the facility in April of 2025 and became aware of the pest problem towards the end of May of 2025. The ADM stated they had a pest control company that came to the facility twice a month. She stated they switched pest control companies in the beginning of June of 2025 because there was an increase in mouse sightings. The ADM stated the pest control company came out on 06/25/2025 and reported the mouse droppings in Resident #5's room were old. The ADM stated that the risks to the residents were that they could get sick, and everyone was responsible for monitoring for mice or mice droppings. The ADM stated her expectation was to continue the interventions and keep the facility as pest-free as they could.During an interview on 06/26/25 at 10:29 A.M., a Pest Control Technician (PCT) stated their company came to the facility on [DATE] and set up all new exterior and interior rodent traps. The PCT stated two traps were placed in each resident's room, for a total of 54 traps. The PCT stated the traps were placed inside secure boxes (the black boxes) to protect the residents, and there had been no activity found since the traps were placed. The PCT stated the mouse droppings in Resident #5's room were old because the droppings were gray, brittle, dry, and had no odor. The PCT stated if there was an active infestation then they would have caught a mouse in one of the 54 traps that were set. The PCT stated that usually a mouse would be caught within 24 to 48 hours. The PCT added that the facility had followed all the recommendations from the pest control company and were doing everything to ensure the facility was pest-free.During an interview on 06/25/25 at 3:56 P.M., the ADM stated the facility staff decluttered and cleaned all resident rooms. Every resident was provided with a plastic tub to store their snacks, and families were asked to keep all the food in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366040 If continuation sheet Page 9 of 10 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 06/27/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete containers. The ADM stated that on 06/03/25 a notice was sent to the families to see if they wanted to help clean the residents' rooms. The ADM stated the pest control company came almost every day for the first week of June 2025 and searched the entire building for entry points. The ADM stated that on 06/05/25 the pest control company placed metal mouse traps around the facility. Then on 06/06/25 the pest control company placed three additional outdoor big black box mouse traps. The ADM added that on 06/06/25 they decluttered, shampooed, and cleaned all the rooms on the LTC unit. The ADM stated the facility also obtained two outside cats to assist with pest control, hired a company to remove trees and brush around the facility on 06/08/25, and had the air conditioner units sealed to prevent points of entry.Review of a facility policy titled, Pest Control, revised in 06/2021, revealed, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.This deficiency represents non-compliance identified under Master Complaint Number OH00166955 (iQIES Complaint Number 1372879) and Complaint Number OH00162627 (iQIES Complaint Number 1372877). Event ID: Facility ID: 366040 If continuation sheet Page 10 of 10