Health inspection·November 14, 2019

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review and staff interview, the facility failed to develop a comprehensive care plan to address the resident diagnoses and treatment for hypertension and anxiety. This affected one (#48) of 18 residents reviewed for care plans. The facility census was 63. Findings include: Medical record review for Resident #48 revealed an admission date of 07/01/19. Diagnoses included adjustment disorder, hypertension and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/21/19, revealed Resident #48 had no cognitive impairment. Review of the physician orders, dated 07/01/19, revealed orders for antihypertensive medications named Metoprolol Succinate extended release (ER) tablet, Losartan potassium tablet, Hydrochlorothiazide and and an antianxiety medication named Xanax. Review of the care plan, dated 07/29/19, revealed it was silent to addressing the resident's diagnoses of hypertension and anxiety and the medications to treat it. The care plan was updated on 11/13/19 for the anxiety medications and was silent for the hypertensive medications. Interview on 11/14/19 at 9:35 A.M. with the Director of Nursing (DON) confirmed the care plan had been updated on 11/13/19 and she would have expected it should have been done at the time of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 2 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview, the facility failed to maintain an accurate care plans for Resident #7 and #52 and failed to invite the resident and/or family members for care conferences quarterly for Resident #15. This affected three (#7, #15 and #52) of 19 residents who were reviewed for care plan accuracy. The facility census was 63. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, pseudobulbar, dementia and hemiplegia. Review of the physician orders, dated 08/27/19, revealed to place a pummel cushion (prevents sliding further) to the resident's wheelchair and check the placement every shift, dated 08/27/19. On 08/27/18, there was an order to place a dycem (non slip pad) under the pummel cushion to the wheelchair and check the placement every shift. Review of the treatment administration record (TAR), dated 11/2019, revealed the facility staff were placing their initials on the TAR twice daily indicating Resident #7 had dycem under the pummel cushion in the wheelchair, and the pummel cushion to the wheelchair and checking placement every shift, indicating the staff were verifying the items were in place and in use. Review of the care plans revealed the resident had a care plan that indicated the resident had a pummel cushion to the wheelchair to assist with positioning. There was no mention of a geri-chair in place for the resident. Observation of Resident #7 on 11/12/19 at 9:32 A.M. revealed the resident was sitting in a geri-chair which was being pushed by a staff member. Subsequent observation of Resident #7 on 11/14/19 at 8:25 A.M. revealed the resident was in a geri-chair in the dining room. The geri-chair had no cushion to the chair. During an interview with State Tested Nursing Assistant (STNA) #405 at 11/14/19 at 8:26 A.M., it was revealed the resident only used a geri-chair and without a cushion. During an interview with Licensed Practical Nurse #410 on 11/14/19 at 9:18 A.M. it was verified Resident #7 was not currently using a wheelchair with a pummel cushion, but was using a geri-chair. The LPN verified the resident was using the geri-chair for the current month and verified in the past the resident used a wheelchair with a pummel cushion. The LPN stated he/she was unsure when the changes in chairs occurred. During an interview with Corporate Nursing Consultant # 491 on 11/14/19 at 9:02 A.M., it was confirmed Resident #7's care plan did not include the geri-chair the resident used when out of bed, but continued to have the wheelchair with pummel cushion included in the care plan which was no longer in use. 2. Review of Resident #52's medical record revealed the resident was admitted to the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 3 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 0657 Level of Harm - Minimal harm or potential for actual harm [DATE]. Diagnoses included muscle wasting, coagulation defect, hyperlipidemia, dementia, depression, anxiety, spinal stenosis, and depression. Review of the physician orders and medication administration records revealed the resident was not on a hypnotic medication. Residents Affected - Few Review of the care plan revealed the resident was on hypnotics for short term use only with a created date of 12/18/17 and no revision date. During an interview with Corporate Clinical Specialist #491 on 11/14/19 at 12:21 P.M. it was confirmed the the care plan was not updated to reflect the non-use of a hypnotic medication. 3. Review of the medical record for Resident #15 revealed she was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disorder (COPD), edema and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/23/19, revealed Resident #15 was cognitively intact. Further review of the medical record revealed the resident was offered a care conference on 01/10/19 and on 04/12/19 and declined. The record was silent to any other offer of a care conference after that. Review of the social services notes, dated 06/03/19 and 09/03/19, revealed the social services completed assessment but there was no record of offering a care conference with the resident or family members. Interview on 11/12/19 at 2:14 P.M. with Resident #15 revealed she had not been offered a care conference recently and could not recall the last time she had been offered one. Interview on 11/13/19 at 4:30 P.M. with Admissions #427 revealed the facility did offer care conferences by sending out a letter out to the residents and family members on 07/17/19 stating if they wanted a care conference they could call and set up one up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 4 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory testing as ordered. This affected one (Resident #352) of five residents reviewed for unnecessary medications. The facility censes was 63. Findings include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including adverse effects of anticoagulants, muscle wasting, coagulation defect, hyperlipidemia, depression, anxiety and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/23/19, revealed the resident was cognitively impaired and the resident received seven days of antipsychotic, antianxiety, hypnotic and anticoagulant medications. Review of the physician orders, dated 07/2019, revealed the resident had laboratory testing orders which included a vitamin D level every three months on the first Monday in the months of August, November, February, and May. Review of the laboratory results revealed the resident had not had a vitamin D level completed in August 2019 or November 2019 as ordered, and the last vitamin D level was completed on 06/24/19. During an interview with Corporate Clinical Specialist #491 on 11/14/19 at 12:21 P.M. it was confirmed the facility did not complete laboratory testing as ordered by the physician and the resident had not had a Vitamin D level completed in August 2019 and November 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 5 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's hospice contract, the facility failed to designate a facility team member for the collaborate of care between hospice services and the facility. This affected three resident (#12, #44 and #45) of three residents reviewed for hospice services. The facility identified 11 residents receiving hospice services. The facility census was 63. Findings include: 1. Medical record review for Resident #44 revealed an admission on [DATE]. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/17/19, revealed the resident had an impaired cognition and the resident was receiving hospice services. Review of the physician orders, dated 04/14/19, indicated to admit the resident into hospice care related to end stage Alzheimer's disease. Review of the plan of care, dated 04/16/19, revealed the resident was receiving hospice services related to late stage Alzheimer's disease. Interventions included for hospice to collaborate with the facility staff and to contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. 2. Medical record review for Resident #45 revealed an admission date of 01/11/17 with diagnoses including metabolic disorder, cirrhosis if the liver and jaundice. Review of the quarterly MDS assessment, dated 10/18/19, revealed the resident had impaired cognition and was receiving hospice services care. Review of physician orders, dated 07/11/19, revealed an order for Resident #45 to be admitted to hospice services. Review of the plan of care, dated 07/29/19, revealed hospice services were in place for end stage cirrhosis of the liver. Interventions included hospice to collaborate care with facility staff contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. 3. Medical record review for Resident #12 revealed an admission on [DATE] with diagnoses including dementia with Lewy bodies. Review of the quarterly MDS assessment, dated 08/26/19, revealed the resident had impaired cognition and was receiving hospice services during the look back period. Review of the physician orders, dated 05/22/19, revealed an order for Resident #12 to be admitted to hospice services. Review of the plan of care, dated 05/23/19 revealed the resident was receiving hospice services for end stage Lewy body dementia. Interventions included for hospice to collaborate care with facility staff and contact hospice for changes in the resident's condition. The plan of care was silent regarding the name and title of the designated facility staff member for coordination of care with hospice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 6 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 Review of the hospice contract with the facility, dated 11/01/17, reveals the facility will designate a member of its interdisciplinary team who will be responsible for working with hospice to coordinate care provided to the hospice patients. Interview on 11/13/19 at 4:45 P.M. with Director of Admissions verified the facility does not have a specific staff member to communicate with hospice to coordinate care. She stated if it was a new hospice referral, the social worker will set up the meeting with the family and assist with admission process. Interview with Licensed Practical Nurse (LPN) #461 on 11/14/19 at 11:45 A.M. verified the hospice staff will report to the facility nurse when a visit is made and if any follow up will be needed as a result of the visit. The LPN stated she was unaware of a designated facility staff member that collaborates care and services with hospice. Interview on 11/14/19 at 2:10 P.M. with the Clinical Corporate Specialist #491 verified the facility did not designate a facility staff member for the collaboration of hospice services and determination of the services hospice will provide for Resident #12, #43 and #44. Subsequent interview on 11/14/19 at 3:08 P.M. with Clinical Corporate Specialist #491 verified the facility was now completing audits to correct the plan of cares that have been impacted with the lack of documentation regarding a designated staff member for continuation of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 7 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 Based on observation, review of facility policy and staff interview, the facility failed to ensure the staff served the resident's meals in a sanitary manner. This affected two (#2 and #26) of 63 residents observed for dining observation. The facility census was 63. Residents Affected - Few Findings include: Observation of the meal tray delivery on 11/12/19 at 12:48 P.M. in the memory care unit revealed State Tested Nursing Assistant (STNA) #403 applied hand sanitizer prior to pulling a meal tray from the delivery cart. STNA #403 preceded to place a meal tray on the dining room table in front of Resident #26. STNA #403 then removed her personal eye glasses from her head and placed them on her face. STNA then tucked her hair behind her ears using both hands. STNA #403 then opened a wax paper bag with a dinner roll inside and placed in on the plate of food without reapplying hand sanitizer and gloves prior to handling the dinner roll. A subsequent observation on 11/12/19 at 1:01 P.M. in the memory care unit revealed STNA #403 applied hand sanitizer prior to a pulling meal tray from the delivery cart. STNA #403 preceded to place a meal tray on the dining room table in front of Resident #2. STNA #403 proceeded to remove the dinner roll from the wax paper bag and place it on the plate of food. STNA #403 then handled a facility dining room chair using both hands on the arm rests and pulled it close to Resident #2. Then, STNA #403 did not use hand sanitizer and gloves before picking up the dinner roll and proceeding to cut the roll in two and placing butter on both sides of the roll and then placing the item on the food plate of Resident #2. Interview on 11/12/19 at 2:42 P.M. with STNA #403 verified she touched her hair and the arms of the dining room chair and did not sanitizer her hands and use gloves before touching the resident's food with her bare hands. Review of the facility's policy titled Provider Services, infection control policy and procedure manual, dated 10/18/01 with a revision of 08/2016, revealed the facility failed to follow guidelines for safe food handling. The policy stated the food handlers mush wash their hands after engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 8 of 9 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 366198 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing Center 2436 Old Oxford Road Hamilton, OH 45013 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, the facility failed to keep resident equipment in safe operating condition. This affected three (#2, #7 and #43) of 19 residents reviewed for equipment. The facility census was 63. Residents Affected - Few Findings include: Observation of Resident #2's geri-chair on 11/12/19 at 5:20 P.M. revealed the geri-chair arms were in disrepair and torn up. Observation of Resident #7's room on 11/12/19 at 2:32 P.M. revealed the over bed light was missing a pull cord. Observation of Resident #43's wheelchair on 11/14/19 at approximately 11:00 A.M. revealed the wheelchair arms were in disrepair and the vinyl was missing on the ends of the bilateral wheelchair arms. During an interview and observation with State Tested Nursing Assistant (STNA) #457 on 11/14/19 at 2:51 P.M. it was confirmed there was no call light pull cord for Resident #7's over the bed light. The STNA also confirmed the arms to Resident #2's geri-chair and the arms to Resident #43's wheelchair were in disrepair and the vinyl was off the ends of the arms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366198 If continuation sheet Page 9 of 9