Health inspection·October 3, 2019

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the wound care notes, dated 08/30/19, revealed Resident #63 had an unstageable pressure area (full thickness or skin tissue loss with depth unknown) noted to her coccyx, with new orders to apply calmoseptine cream every shift and as needed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/02/19, revealed Resident #63 had no pressure injury noted with no ulcers, wounds, and/or skin problems noted. Interview on 10/02/19 at 8:28 P.M. with MDS Coordinator Registered Nurse (RN) # 155 verified Resident #63's MDS assessment dated [DATE] was incorrect, with no documentation of the pressure area to the coccyx. RN #63 state it was completely missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 2 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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, review of the hospital record, staff interview, and review of the facility policy, the facility failed to provide timely care for a resident following a fall. This affected one (#63) of one resident reviewed for accidents during the investigation stage of the annual survey. The facility census was 73. Residents Affected - Few Findings include: Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses included insomnia, constipation, chronic muscle pain, dementia and osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/02/19, revealed Resident #63 was severely cognitively impaired with verbal behaviors directed toward other one to three days during the look-back period. The resident required extensive one-person assistance with dressing, personal hygiene, extensive two-person assistance with bed mobility and total two-person assistance with transfers. Review of the MDS assessment, dated 08/20/19 revealed the resident received non-medication interventions along with scheduled and as needed medications for pain. Resident #63 was noted during that time with a fall with major injury since admission/prior assessment. Review of the nursing progress notes, dated 07/23/19 at 3:20 P.M., revealed Resident #63 was found laying on the floor in her room, next to the bed and the physician was notified of the fall with no injury. Resident #63 was noted with a complaint of right knee pain but had chronic pain and voiced no new complaints of pain. Subsequent review of the resident's progress notes, revealed on 07/23/19 at 3:39 P.M., the resident was administered her as needed Hydrocodone-Acetaminophen (a narcotic pain medication, also known as Norco) 5-325 milligram (mg.) tablet for her complaint of right knee pain. The progress note, dated 07/24/19 at 5:45 A.M., revealed the resident was provided as needed Tylenol 650 mg. for complaint of bilateral knee pain with her pain rated at a five, on a pain scale of zero (no pain) to ten (most severe pain). On 07/24/19 at 1:43 P.M., Resident #63 was provided her as needed Norco for pain. On 07/25/19 at 3:58 A.M., Resident #63 was provided her as needed Norco for complaint of right knee pain. There was no notification noted where the physician was notified of the increased pain in the right knee. Review of the MAR, dated 07/01/19 through 07/31/19, revealed Resident #63 received scheduled Norco 5-325 mg., two times daily at 9:00 A.M. and 9:00 P.M. for pain. The resident ' s pain was noted to be zero from 07/01/19 through 07/23/19, except for three occasions, the pain was rated at a three on 07/07/19, 07/09/19 and 07/23/19. The pain level increased on 07/24/19, the day after the resident fell. On 07/24/19 at 9:00 P.M., Resident #63 was noted with a pain scale of seven. On 07/25/19 at 9:00 P.M., the resident was noted with a pain scale of eight. On 07/26/19 at 9:00 A.M., the resident was noted with a pain scale of 10 and at 9:00 P.M. the resident was noted with a pain scale of eight. Further review of the MAR revealed the resident had as needed (PRN) medications Tylenol 650 mg. every six hours, and Norco 5-325 mg. every four hours as needed. There were no doses of either medication administered to the resident from 07/01/19 through 07/22/19. Resident #63 was noted on the MAR as provided the Norco for pain on 07/23/19 at 3:39 P.M. rated at three, on 07/24/19 at 1:43 P.M. for pain rated at nine, and again on 07/25/19 at 3:58 A.M. for pain rated at four. Further review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 3 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 MAR revealed the resident was also provided the PRN Tylenol 650 mg. on 07/24/19 at 5:45 A.M. for pain rated at a five. Subsequent review of the progress note, dated 07/27/19 at 10:10 A.M., revealed the physician was called regarding Resident #63's complaint of right and left knee pain with swelling noted. A new order was received for x-rays of both knees. On 07/27/19 at 2:15 P.M., the physician was notified of the right knee non displaced fracture of the distal femur and the left knee non displaced fracture of the left lateral femur. The physician ordered for the resident to be sent out to the local hospital. Review of the local hospital after visit summary, dated 07/27/19, revealed Resident #63 was seen in the emergency department and diagnoses included closed fracture of lateral condyle of left femur and closed fracture of medical condyle of the right femur. The resident fitted with a large knee immobilizer placed on the right knee and medium knee immobilizer placed on the left knee and consulted for local orthopedic physician outpatient. Interview conducted on 10/03/19 at 10:35 AM. with the Assistant Director of Nursing (ADON) #28 reviewed the fall for Resident #63. ADON #28 stated the staff notified they doctor on the date of the fall, on 07/23/19, and there was a noted increase of pain and swelling on the 27th and that was what triggered them to call the physician a second time and get an order. ADON #28 stated between 07/23/19 to 07/27/19, the resident was at her baseline and did not require physician notification/intervention. At that time, the surveyor reviewed Resident #63's MAR and progress notes dated 07/01/19 through 07/31/19 with ADON #28 who verified resident was documented with increased pain scale requiring the use of PRN pain medication from 7/23/19 through 7/27/19. ADON #28 verified Resident #63 did not use any PRN pain medication the entire month prior and was noted with the highest complaint of pain at a three out of 10 pain scale, and following the fall was noted with a pain scale from a seven to nine out of 10. ADON #28 verified there was no other physician notification between the fall on 07/23/19 to 07/27/19, of the residents increased complaints of pain. ADON #28 stated he would have to review the incident further, however was never able to provide additional information during the survey. Review of the facility policy titled, Change in a Resident's Condition or Status, with a revision date of 04/2014, revealed the facility would notify the attending physician in changes in the resident physical/emotional/mental condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 4 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on medical record review, review of facility policy and staff interview, the facility failed to effectively provide a restorative program to Resident #14. This affected one (Resident #14) of one resident reviewed for restorative therapy. The facility identified 42 resident receiving rehabilitation services. Findings include: Medical record review for Resident #14 revealed an admission date of 01/09/16. Diagnoses included edema, dizziness, mental disorders, arthritis, dementia without behaviors and spinal stenosis. Review of the Minimum Data Set (MDS) assessment, dated 06/28/19, revealed the resident had intact cognition. The resident required extensive assistance for bed mobility and transfers. Ambulation occurred only once or twice in the look back period and no set up help or physical assistance from staff was provided. The resident was coded as having a restorative ambulation program during the look back period and participated one day. Review of the plan of care revealed the resident was on a restorative nursing program for ambulation to improve ambulation related to balance problems, unsteady gait, weakness and limited endurance. The goals included for the resident to remain full weight bearing, free of decline in mobility status and ambulate daily. Interventions included to assess for dizziness, unsteady gait, impaired balance or fatigue, assess walker for correct height (top of walker should match crease in wrist when standing straight up), assist in putting on socks and well-fitting nonskid shoes, provide caution to take small steps when turning, not step all the way to the front bar of the walker, not take a step until all four legs of the walker were level on the ground, not place walker too far ahead, not lean forward over walker, encourage participation in ambulation program, provide rest periods as needed, physical therapy or occupational therapy as indicated, and encourage to complete ambulation program 7.5 minutes per day six to seven days per week. Interview with Physical Therapy Assistant #111 on 10/04/19 at 3:20 P.M. stated the facility used to have a state tested nursing assistant (STNA) to complete the restorative program but now they have a nurse that does it. Interview with State Tested Nursing Assistant (STNA) #100 on 10/04/19 at 3:18 P.M. verified that she was assigned to Resident #14 and did not do any restorative programs for Resident #14 as they have a nurse that does that now. Interview with Licensed Practical Nurse #22 on 10/04/19 at 3:25 P.M., verified the resident had a restorative program for ambulation to be done six to seven days a week. LPN verified restorative treatments for the last 30 days were documented as provided only on thirteen days, 09/04/19, 09/09/19, 09/10/19, 09/11/19, 09/14/19, 09/18/19, 09/20/19, 09/22/19, 09/23/19, 09/24/19, 09/27/19, 09/29/19 and 09/30/19. Review of the facility's policy titled Restorative Nursing Care, dated 07/2013, revealed rehabilitative nursing care is provided for each resident admitted to the program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 5 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to maintain water temperatures within the required 105 minimum to 120 degree Fahrenheit maximum temperatures. This affected resident room [ROOM NUMBER], and the shared resident bathrooms located on the 100 and 200 hallways. This had the potential to affect 19 residents the facility identified as cognitively impaired and independently mobile. The facility census was 73. Findings include: Observation of the water temperature was conducted on 09/30/19 at 3:30 P.M. A test of a resident's shared bathroom revealed the water was extremely hot to touch, with steam noted coming from the faucet. The water temperature was conducted with temperature noted at 128 degrees Fahrenheit (F). Observation and interview conducted on 09/30/19 at 3:41 P.M. with Maintenance Director (MD) #10 revealed resident room [ROOM NUMBER]'s water temperature was at 128.1 degrees F. on the MD #10's thermometer. Observation the bathroom shared by the residents on the 100 hall revealed the water temperature was 129.5 degrees F on the MD #10's thermometer. Observation of the bathroom shared by the residents on the 200 hall revealed the water temperature was at 128.8 F degrees. MD #10 verified the water temperatures were too high/hot during the time of observation. Review of the facility's policy titled, Safety of Water Temperatures, dated 12/2009 revealed the facility would keep tap water temperatures no more they 120 degrees F to prevent scalding of residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 6 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to timely address a gradual dose reduction (GDR) recommendation and physicians orders for medication changes. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The facility census was 73. Findings include: Medical record review for Resident #35 revealed an admission on [DATE]. Diagnoses included dementia, bipolar disorder and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had impaired cognition and the resident was taking an antidepressant medications all seven days during the look back period. Review of the pharmacy recommendations, dated 08/07/19, revealed the resident was currently receiving an antidepressant Venlafaxine (antidepressant) extended release (ER) 150 milligrams (mg.) daily since 12/03/18. The physician wrote an order to decrease Venlafaxine to 100 mg. daily on 09/13/19. Review of the physician's orders for Resident #35 for the month of September revealed an order to discontinue Venlafaxine ER 150 mg. on 09/17/19 and to start Venlafaxine 100 mg. daily on 09/18/19. This was four days after the physician wrote to decrease Venlafaxine to 100 mg. daily. Interview with Director of Nursing (DON) on 10/03/19 at 4:30 P.M. stated the pharmacy will send the GDR in a folder with the medication delivery about ten days after the review of the resident's medical record. If there were any recommendations, they were placed in the physician's box at the facility. He will pick them up and take them with him. After the physicians reviews them, he will bring them back to the facility and any new orders will be addressed. The DON stated this particular physician does not come in very often. The DON stated the facility's time line for addressing the GDR's was between 30 and 60 days to complete the recommendations. She verified the orders were written on 09/13/19 by the physician and not put in to the electronic health record until 09/17/19. Resident #35 received a higher dose for four additional days. Review of the facility's psychotropic/psychopharmacological medication policy, dated 2017, revealed the facility's pharmacist will monitor psychoactive drug use in the facility to ensure medications are not used in excessive dosages for excessive durations as well as for potential adverse interactions, notify the physician and nursing administration when a psychotropic medication is past due for review, ensure proper timelines are followed per regulatory guidance for dosage reduction attempts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 7 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview, and review of facility policy, the facility failed to monitor for the continued need for psychotropic medication. This affected one (Resident #35) of five residents reviewed for unnecessary medications. The facility census was 73. Residents Affected - Few Findings include: Medical record review for Resident #35 revealed an admission on [DATE]. Diagnoses included dementia, bipolar disorder and depression. Review of the Minimum Data Set assessment, dated 07/31/19, revealed the resident had impaired cognition and the resident was taking an antidepressant and antipsychotics medication all seven days during the look back period. Review of the plan of care revealed an initiation date of 01/22/19 with a revision date of 06/18/19. The resident was at risk for complications related to the use of psychotropic medication. Interventions included to document any adverse effect to routine or as needed medication (PRN), staff was to monitor for tremors or changes in mental status, notify physician with any problems and complete a quarterly abnormal involuntary movement scale (AIMS). Review of the physicians orders, dated 10/2019, revealed an order for Ariprazole (antipsychotic) tablet 10 milligrams (mg.), give one tablet by mouth one time a day with a start date of 12/04/18. Further review of the medical record for Resident #35 revealed there was no AIMS assessments available for review. The medical record was silent for any other monitoring for abnormal movement related to antipsychotic medication. Interview on 10/02/19 at 2:07 P.M. with Registered Nurse #217 verified the AIMS tests was not completed as it should have been. Review of the facility's policy titled Psychotropic/psychopharmacological Policy, dated 2017, revealed the facility did not implement the policy in regards to the allegation. Number 13 states the facility will conduct AIMS testing at least every six months and as needed to monitor for movement disorders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 8 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to provide rationale and duration for continued use of an as needed (PRN) psychotropic medication. This affected one (Resident #21) of five residents reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 73. Findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/10/19, revealed Resident #21 was severely cognitively impaired with delirium behaviors of disorganized thinking continuously present. The resident received antianxiety medication three days of the seven day look back period. Review of the physician orders revealed Resident #21 was ordered psychotropic medications including Lorazepam (Ativan), ordered 05/03/19, as needed (PRN) every six hours for anxiety/agitation and prior to showers. Review of the Medication Administrator Record revealed Resident #21 was provided the PRN Ativan 27 times from 05/01/19 through 09/30/19. The resident received the PRN Ativan on the following dates: on 05/03/19, 05/04/19, 05/07/19, 05/22/19, 05/24/19, 05/29/19, 05/31/19, 06/05/19, 06/07/19, 06/12/19, 06/14/19, 06/21/19, 06/26/19, 06/28/19, 07/03/19, 07/05/19, 07/09/19, 07/10/19, 07/14/19, 07/17/19, 07/18/19, 07/19/19, 07/24/19, 07/26/19, 08/02/19, 09/04/19 and 09/06/19. Further review of the medical record was silent of continued monitoring for behaviors, side effects, and/or effectiveness for the continued use of the psychotropic medications. Interview on 10/03/19 at 12:31 P.M. with the Director of Nursing (DON) #4 stated her understanding was that residents wee able to have orders for PRN Ativan for greater than 14 days without a physician's documentation. DON #4 then verified she was misinformed regarding the use of PRN Ativan, and verified Resident #21 had continued receiving the medication PRN without the required documentation of rationale and verified the duration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 9 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 - Many 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. Based on observation and staff interview, the facility failed to ensure expired medications and laboratory supplies were discarded appropriately. This had the potential to affect all 73 residents residing in the facility. Findings include: Observation of the medication room on level one on 10/03/19 at 9:11 A.M. revealed the following three vials of laboratory specimen medium for stool culture and sensitivity testing with expiration dates of 02/2019 and two vials of Remel transport for mycoplasma and ureaplasma (a virus test) with an expiration date of 08/2019. All other laboratory supplies being stored were not expired. One unopened stock bottle of certerizine tablets (antihistamine) with an expiration date of 07/2019 was observed being stored in the medication room. Observation of medication being stored in the medication room's refrigerator revealed 10 Promethazine suppository's (controls nausea and vomiting) for Resident #31 that were expired on 07/2019. Interview with the Director of Nursing on 10/03/19 at 9:30 A.M. verified there were expired medication, and laboratory supplies stored in the level one medication room. Observation of the medication room on level two on 10/03/19 at 8:37 A.M. revealed the following four vials of laboratory specimen medium for stool culture and sensitivity testing with expiration dates of 02/2019 and one vial of Remel transport for mycoplasma and ureaplasma with an expiration date of 08/2019. All other laboratory supplies being stored were not expired. Interview with the Licensed Practical Nurse #22 on 10/03/19 immediately following the observation verified there were expired laboratory supplies stored in the level two medication room during the survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 10 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0791 Provide or obtain dental services for each resident. 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 and staff and resident interviews, the facility failed to provide assessments for routine dental care. This affected one (Resident #9) of one resident reviewed for dental services in the investigation stage of the annual survey. The facility census was 73. Residents Affected - Few Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included gastro-esophageal reflux, anxiety disorder and chronic obstructive pulmonary disease. Further review of the medical record revealed Resident #9's payer source was Medicaid, effective in 06/2018. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/21/19, revealed the resident was cognitively intact, with no noted behaviors and/or refusal of care noted. Review of Section L Oral/Dental status revealed the resident had no broken teeth and/or dental concerns noted. Interview on 09/30/19 at 11:06 A.M. with Resident #9 stated she had not seen the dentist since being admitted to the facility. Resident #9 stated it had been about three years since she had been seen, and her top plate needed some work and she had some cavities in the bottom teeth that needed looked at. Interview on 10/02/19 at 2:36 P.M. and again on 10/03/19 at 12:08 P.M. with Social Services (SS) #53 stated residents were assessed on admission if they would like to be seen by ancillary services, and then they were added as needed and yearly to the visit list. SS #53 stated residents were reminded throughout the year at resident council when services were coming in, so they can be added if they would like to be seen. SS #53 verified she was aware Resident #9 doesn't get of bed to go to resident council. SS #53 was unable to voice how residents that do not attend resident council are aware of services. SS #53 stated she was not working in the facility when Resident #9 initially signed for services but she should have been reassessed when she changed payer source from Medicare to Medicaid. SS #53 verified the resident was not reassessed when payer sources changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 11 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview and review of facility policy, the facility failed to ensure meals were served in a safe and appetizing temperature. This affected three (Resident #38, #116 and #122) of 12 residents observed on the second floor dining room. This had the potential to affect all 12 residents in the second floor dining room. The facility census was 87. Residents Affected - Some Findings include: 1. Observation on 09/30/19 at 10:02 A.M. to 10:09 A.M., revealed Resident #116's meal was sitting next her and the tray was left covered. Resident #116 was yelling requesting for a cup of water and some milk. Observation on 09/3/10 at 10:21 A.M., revealed State Tested Nursing Aide (STNA) #88 started to assist Resident #116 with her meal. Interview on 09/30/19 at 10:22 A.M. Assistant Director of Nursing (ADON) reported food trays comes on the floor for Resident #116 at 9:00 A.M. Interview and observation on 09/30/19 at 10:23 A.M. with Registered Dietitian (RD) #36 revealed the RD took the temperature of Resident #116's food. RD #36 took the temperature of Resident #116's food and the scrambled eggs were 85 degrees Fahrenheit (F) and fat free milk at 48.2 degrees F. RD #36 verified the temperatures of the food served to Resident #116 were not at the appropriate temperatures. RD #36 reported she was a new employee and will investigate the matter. 2. Observation on 09/30/19 at 12:10 A.M. revealed Resident #122's food was placed on the counter top in the dining room away from the resident. At 12:36 P.M., Resident #42 received her meal. Interviews on 09/30/19 at 12:43 P.M. with Resident #38 and #122 revealed they both complained that their meals were not warm, and their bread was hard. Interview and observation on 09/30/19 at 12:44 P.M., revealed RD #36, took the temperatures of Resident #38's food. RD #36 took the temperature of Resident #38's food and the goulash ham was 124 degrees F., the au gratin potatoes were 85 degrees F., and the baby carrots were 74 degrees F. RD #36 reported food should be at a holding temperature of 135 degrees F and reported the garlic bread was overcooked. Review of the facility's policy titled, Food Preparation and Service, revealed temperatures at the point of service should be at least 135 degrees F for hot foods and for cold foods below 40 degrees F. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 12 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 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 review of facility policy, the facility failed to label, date, cover and discard outdated food items from the walk-in refrigerator and freezer. The facility also failed to keep the utensil bins cleaned. This had the potential to affect 84 of the 87 residents residing in the facility. The facility identified three residents (#41, #56 and #68) who did not receive food by mouth. Findings include: On 09/30/19 at 8:30 A.M., an initial tour of the kitchen was conducted with Registered Dietitian (RD) #36. During the observation the following concerns were verified by RD #36: In the refrigerator, there was an opened bag of turkey breast and a container of tuna fish with no date of opened or a use by date. There was a bag of shredded cheese, dated 06/14/19, and there was no date of opened or use by date. There was a bag of roast beef with a date of 09/05/19 and there was no date of opened or use by date. The utensil bin stored in the kitchen was dirty and filled with old food particles, dust and dirt-like particles on the edges and inside the bin, where the clean utensils were kept. [NAME] (CK) #9 verified findings of utensil storage filled with food crumbs, dust and dirt-like substances. Review of the facility's list of residents whose diet order was nothing by mouth revealed Resident #41, #56 and #68 had diet orders of nothing by mouth. Review of the facility policy titled, Food Receiving and Storage, revised December 2008, revealed food services, or other designated staff, will maintain clean food storage areas at all times. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 13 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on record review, staff interview, hospice staff interview and facility-hospice contract, the facility failed to collaborate on a comprehensive plan of care and failed to designate a staff member who was responsible for working with hospice to coordinate care to the resident by both providers. This affected one (Resident #26) of two residents reviewed for hospice services. The facility identified 13 residents who receive hospice services. The facility census was 73. Findings include: Medical record review for Resident #26 revealed an admission of 04/10/14. Diagnoses included muscle weakness, anxiety, mood disorder, displaced fracture of neck, psychosis, transient cerebral attack, major depression and Parkinson's disease. Review of the physician order, dated 04/28/18, revealed an order to admit the resident to hospice services. Review of the quarterly assessment, dated 07/05/19, revealed the resident had impaired cognition and was receiving hospice services. Review of the plan of care revealed the resident was receiving hospice services related to late stage Parkinson's disease. Interventions included to contact dietary to provide a courtesy cart as needed, encourage the resident to verbalize feelings and concerns about end of life issues, provide validation, notify the social worker, clergy as needed, encourage my family to verbalize feelings and concerns about end of life issues. Notify social worker/clergy as needed, receives supplemental services through Hospice Provider #1 with a telephone number listed. The resident will be visited by a State Tested Nursing Assistant (STNA) two to three times weekly, a Registered Nurse (RN) weekly, a Social Worker and Clergy weekly and as needed. The resident desired comfort care, comfort foods as desired, no tube feeding, notify hospice agency for any changes in condition or unmet needs of the resident or family/friends. Staff were to observe for changes in condition, pain, level of consciousness, etc, notify Case Manager Nurse and hospice agency. There was no designated staff member listed for communication with hospice services. Review of the hospice contract with the facility, dated 10/21/09, revealed hospice and facility will jointly develop and agree upon a coordinated plan of care which was consistent with the hospice philosophy and was responsive to the unique needs of the hospice patient and his or her expressed desire for hospice. Additionally, the contract stated that the plan of care will identify which provider was responsible for performing the respective functions that have been agreed upon and included in the plan of care. Under the coordination of care section, the contract states the hospice and the facility shall communicate with one another regularly and as needed for each patient, each party was responsible for documentation such communications in its respective clinical record to ensure the needs of the hospice patient are met. Review of the social services notes for Resident #26, dated 08/19/19 at 2:50 P.M., revealed a care conference was held social services, nursing, activities, and the resident's family. Resident did not attend secondary to decreased cognitive functioning and inability to provide meaningful participation. The attending physician involved in the patient's plan of care via review and revision of physician orders but not present at meeting. There was no mention any hospice staff involvement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 14 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Hospice Registered Nurse (RN) #201 at 1:45 P.M. on 10/01/19 verified there was no meeting to develop a comprehensive care plan between the hospice agency and the designated facility staff member. Hospice RN #201 stated she will talk with the nurse that was caring for the residents that she visited and give them any updates or changes but it was not the same nurse all the time. Additionally, the Hospice RN stated that she was invited to the care conferences but could not attend all of them due to time constraints related to resident care. Interview with the Director of Nursing and Licensed Social Worker (LSW) #53 on 10/02/19 at 2:30 P.M. revealed the LSW stated there was not a designated staff member identified to communicate with hospice on an ongoing basis. LSW further stated that she does invite hospice to the care conference but they do not always attend. The LSW denied any other documents that she maintained to document the collaboration between the facility and the hospice provider. Review of the facility's policy titled Hospice Program, with a revision date of 04/2014, stated when a resident participated in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 15 of 16 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 366159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Birchwood Care Center 4070 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on facility record review and staff interview, the facility failed to maintain the minimum required committee members for the Quality Assessment and Assurance (QAA) quarterly meetings. This had the potential all 73 residents residing in the facility. Residents Affected - Many Findings include: Facility record review and staff interview was conducted on 10/03/19 at 7:12 P.M. with Corporate Administrator (CA) #189. Review of the QAA quarterly meetings revealed there were four noted meetings conducted, as required. However an Administrator did not attend two of the four meetings held on 01/18/19 and 07/19/19. CA #189 verified the Administrator was not signed in for attending the meetings. CA #189 stated the Administrator did not attend due to he was a single father and may have had something with his daughter at the time of the meetings and was unable to attend. CA #189 verified she was aware an Administrator was required to attend and there was no Administrator present during those two quarterly meetings, as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366159 If continuation sheet Page 16 of 16