Health inspection·March 28, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the daughter of Resident #382 on 03/25/19 at 1:02 P.M. it was confirmed she was the person the facility would call with change of conditions and the daughter stated she has not been called by the facility with any changes on her mother. During an interview with the Director of Nursing (DON) on 03/28/19 at 11:00 A.M. it was confirmed the family was not notified of the change in the Coumadin dose that occurred on 03/25/19 relating to the PT/INR results. The DON stated the family does not wish to be notified of small changes. The DON was asked where that was documented and the DON stated she just got off the phone with the daughter and was informed that the daughter trusted the facility and did not want called unless the facility thought it was a big change in her condition. The DON verified there was no documentation of the family not wanting to be notified in the medical. Review of the Change of Condition policy dated 10/18/01 with revision dates of April 2002 and April 2003 revealed a change in condition is defined as deterioration in health, mental or psychosocial status of a resident related to a life-threatening condition, a significant alteration in treatment, or a significant change in the resident's clinical condition or status. Significant alteration in treatment is defined as a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new treatment or the decisions to transfer a resident to a hospital. Further review of the procedure revealed the Unit supervisor or charge nurse will notify the resident, physician and guardian/interested family member of all changes as stated above and the person doing the notification will document all notification in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff, family and resident interview, the facility failed to develop person centered care plans for two (#47 and #383) residents regarding their activity preferences, and one (#80) resident for their behavioral needs out of 21 records reviewed. The facility census was 81. Findings include: 1. Review of Resident #47's medical record revealed the resident admitted to the facility on [DATE] and discharged to hospital on [DATE] and re-admitted on [DATE]. Diagnosis include cerebral infarction, muscle wasting, aphasia, dysphagia, hemiplegia, heart failure, Crohn's disease disease, convulsions, and depression. Review of the most recent quarterly minimum data set (MDS) dated [DATE] revealed the resident has a brief interview of mental status score (BIMS) of three indicating the resident is severely cognitively impaired, had no delusions or hallucinations, but had behaviors daily and rejection of care four to six days of the review period. The resident requires extensive assist with daily cares except for locomotion off the unit which the resident is dependent on staff. The resident is coded as always incontinent of bowel and bladder. Review of Resident #47's care plan revealed the resident has a care plan that indicates the resident preferences for daily life and person centered care that are important or somewhat important include: Ability to use the phone in private. Being around animals such as pets, choosing own bedtime until ready, choosing what clothes to wear sweat pants, shirt t-shirt doing things with groups of people. Having a place to lock up personal belongings, to keep safe, having family or significant other involved in care discussions, having snack available between meals keeping up with news. Listening to music, participating in favorite activities, participating in religious activities or practices, reading books, news papers or magazines, receiving a shower, receiving a sponge bath, receiving a tub bath, spending time away from the nursing home, spending time outdoors. Resident #47 also has a care plan intervention that indicated the staff are encouraging the resident to go to to alcoholics anonymous or narcotic anonymous as needed. Lastly Resident #47 has a care plan intervention that indicates the resident is to be provided with all necessary items to perform adequate oral care. During an interview with the Director of Nursing (DON) on 03/27/19 at 10:20 A.M. it was revealed the resident only leaves the facility to go to appointments at this time and is not spending time away form the home as part of preferences for daily life. During an interview with the DON on 03/27/19 at 10:30 A.M. it was confirmed the care plan was not individualized enough to reflect the needs of the resident. The DON agreed the resident bathing preference is not indicated in the care plan, and the care plan has not been customized to reflect the needs or abilities of this specific resident. The DON also verified Resident #47 is not needing the services of alcoholics anonymous or narcotics anonymous at this time. The DON stated that intervention auto populates on the care plan interventions for any resident who has history of alcohol or drug use, even if it is not a current need in the resident's plan of care. The DON verified the resident requires assist with his oral care needs and the facility staff provide that assistance. The DON verified the facility does not care plan on residents who require incontinent care products to supply them with those products and the oral care products interventions is directed a residents who are able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 0656 to provide their own oral care, and not Resident #47. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #383 medical record revealed the resident was admitted to the facility on [DATE], the resident was discharged on 03/07/19 and re-admitted to the facility on [DATE]. Diagnosis include disorder of the brain, muscle wasting, chronic obstructive pulmonary disease, peripheral vascular disease, polyneuropathy, hypoglycemia, type two diabetes, hypertensive retinopathy, cognitive communication deficit, infection following a procedure other surgical site subsequent encounter, and epilepsy. Residents Affected - Few Review of Resident #383's MDS dated [DATE], titled discharged return anticipated revealed resident has memory problems both short and long term problems, no delusions hallucinations or behaviors noted. The resident requires limited assist with daily cares with the exception of eating which is supervision. Resident #383 is always continent, resident took six days of antidepressant and opioid medication and seven days of diuretic medication during the review period. Review of Resident #383's care plan revealed the resident had a care plan that indicated resident preferences for daily life and person centered care that are important or somewhat important include: Ability to use the phone in private. Being around animals such as pets, choosing own bedtime until ready, choosing what clothes to wear jeans, shirt t-shirt doing things with groups of people. Having a place to lock up personal belongings, to keep safe, having family or significant other involved in care discussions, having snack available between meals keeping up with news. During an interview with the DON on 03/27/19 at 3:44 P.M. it was confirmed the activity care plan was not person centered and individualized to meet the needs of the resident. The DON confirmed the care plan was the same as Resident #47's with the exception of the items of clothing listed. The DON stated the facility follows the Resident Assessment Instrument (RAI) manual and does not have a specific care plan policy. 3. Review of Resident #80's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including congestive heart failure, muscle wasting, chronic obstructive pulmonary disease, anemia, hypertension, anxiety, difficulty walking. Review of Resident #80's quarterly MDS assessment dated [DATE] revealed the resident had no cognitive impairment, had behaviors of rejecting care and required supervision with all Activities of Daily Living (ADL). On 03/25/19 at 12:41 P.M., during an interview with Resident #80, an observation was made of the residents' arms which had several small scabs on both arms. When questioned the resident stated, I scratch my arms, it is a nervous habit. On 03/25/19 at 9:55 A.M., an interview was conducted with Resident #80's son also referred to as Medical Power of Attorney (MPOA). During the interview the resident's son stated, Mom has done that for years. She picks at the scabs on her arms, it is a nervous habit she has done for years. Further review of Resident #80's care plan dated 01/25/18 revealed no information related to the resident's behavior of picking or scratching her arms. On 03/27/19 at 2:00 P.M., during an interview Unit Manager Licensed Practical Nurse (LPN) #83 confirmed Resident #80 care plan did not include behaviors for scratching and picking her arms. LPN #83 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 0656 Level of Harm - Minimal harm or potential for actual harm stated Resident #80's care plan was updated today (03/27/19) to reflect her behaviors and the resident was provided Geri sleeves (elastic cloth sleeves) to assist in preventing the resident from scratching and picking at her arms. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 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** 2. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses included arteriosclerotic heart disease, muscle weakness, cognitive communication, syncope, anemia, chronic kidney disease, intervertebral disc degeneration, chronic pain, hypothyroidism, iron deficiency, hyperlipidemia, major depression, anxiety disorder and chronic pain syndrome. Review of the resident's MDS dated [DATE] indicated the resident had no or mild cognitive impairment and had vision impairment. The resident required supervision with activities including transfers, dressing, eating, toileting and personal hygiene and required limited supervision with locomotion. Resident #58 was seen on 03/04/19 by the eye doctor who recommended an evaluation by a cataract surgeon. The resident had an appointment scheduled for 04/02/19. Review of the resident's plan of care (POC) dated 07/27/18 through 05/21/19 indicated the resident had some visual impairments and used reading glasses. The POC did not indicate the resident had cataracts and was awaiting a consultation for cataract surgery. On 03/28/19 at 10:36 A.M. MDS Nurse #90 verified the resident's care plan did not indicated the resident had cataracts and was scheduled to go for consultation to have the cataracts removed. Based on record review and staff interview, the facility failed to ensure care plans were timely updated to accurately reflect the needs of the resident. This affected two (#47 and #58) out of 21 residents reviewed for care plans during the survey. The facility census was 81. Findings include: 1. Review of Resident #47's medical record revealed the resident admitted to the facility 01/28/19, discharged to hospital on [DATE] and re-admitted on [DATE]. Diagnosis include cerebral infarction, muscle wasting, aphasia, dysphagia, hemiplegia, heart failure, Crohn's disease disease, convulsions, and depression. Review of the most recent quarterly minimum data set (MDS) dated [DATE] revealed the resident has a brief interview of mental status score (BIMS) of three indicating the resident is severely cognitively impaired, had no delusions or hallucinations, but had behaviors daily and rejection of care four to six days of the review period. The resident requires extensive assist with daily cares except for locomotion off the unit which the resident is dependent on staff. The resident is coded as always incontinent of bowel and bladder. Review of care plans revealed the care plans are not updated to reflect the resident ability and are not individualized to the residents ability. Resident #47's fall care plan and activity of daily living care plan states to provide assist of one to two with all transfers in the interventions, however the goal for the at risk for falls care plans indicates the resident is a mechanical lift. The resident self care deficit care plan has under the intervention section listed the resident uses a hoyer lift with transfers. Review of Resident #47 physician orders revealed the resident has an order for mechanical lift for all transfers dated 03/06/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON) on 03/27/19 at 10:20 A.M. it was revealed the facility uses two staff with all mechanical lift transfers and Resident #47 uses a mechanical lift for transfers. The DON verified the resident care plan was not accurate and was not timely updated to reflect the resident ability or needs. The DON stated the facility follows the Resident Assessment Instrument (RAI) manual and does not have a specific care plan policy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 - Some 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 observations, staff interview, policy review and review of medication manufacturers information, the facility failed to store refrigerated narcotics securely in two observed medication rooms. The facility identified three medication storage rooms in the facility. This had the potential to affect any resident who received a new order for one of these medications. Additionally, the facility also failed to store resident injectable's accurately in one of three medication carts observed, the facility has a total of seven medication carts. This had the potential to affect 26 resident who receive injectable medications at the facility. The facility census was 81. Findings include: 1. Random observation of the medication storage room on D hall with Licensed Practical Nurse (LPN) #76 on 03/26/19 it was revealed the controlled narcotics that are refrigerated are in a small box in a locked refrigerator in a locked room off the nurses station. The observation revealed the box is removed from the refrigerator to remove the medications. LPN #76 confirmed the narcotic storage box in the refrigerator is not permanently affixed. The narcotic storage refrigerator contained four morphine (opioid analgesic, schedule II medication) 20 milligrams per milliliter (mg/ml) bottles, and seven Ativan (antianxiety schedule IV medication) 2 mg/ml vials. During an observation of the medication room of A and B hallway medication room on 03/26/19 with LPN #85 it was confirmed the refrigerated narcotic emergency supply is not permanently affixed to the refrigerator. The refrigerator contained four vials of Ativan (2 mg/ml in the emergency supply box and one vial if Ativan 2 mg/ml for the B Hall). Review of the controlled substance policy 7.1.2 Storage of Controlled Substances dated 06/21/17 revealed: 5. All controlled medications must be maintained in separately-locked, permanently- affixed compartment. The key (or other access device) cannot be the same system used to obtain non scheduled medications. The facility assures a system is implemented to limit who as security access and when access is used. Schedule II medications must be stored under double lock. Review of the medication storage policy 4.1 general guidelines for medication storage dated 06/21/17 revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medications supply is accessible only to licensed nursing personnel or staff members authorized to administer medications. Scheduled II medications and other drugs subject to abuse are stored in separate, permanently affixed area and are under double lock. Schedule III-IV medications may be stored along with non controlled drugs but may be under more strict storage controls at the facility's discretion or as required by state regulations. 2. During an observation of the B hallway medication cart with LPN #58 on 03/26/19 after morning medication pass it was revealed there was a Levemir insulin pen (multi-dose single patient insulin delivery system) with an open date of 03/23/19 but no resident name on the pen. LPN #58 confirmed the pen was not named, and and had insulin missing out of the pen indicating it had been used. LPN #58 verified she had resident on her hallway who use Levemir used in their plan of care, and all medications should have the name of the resident on them for who they are used for. The facility could not confirm who the Levemir insulin belonged to; however, confirmed it had the potential to affect 26 resident who receive injectable medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue 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 Review of manufactures information regarding the use of Levemir flex touch pen distributed by novo nordisc revealed: Levemir Flex touch pen should not be shared with other people. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 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 366208 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Residence at Huntington Court 350 Hancock Avenue Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's Legionella Water Management Program policies and procedures, review of water monitoring, and staff interview, the facility failed to develop and implement a water management program which specified and monitored control measures to ensure the plan was effective in the destruction of Legionella bacteria. This had the potential to affect all 81 residents residing in the facility. Facility census was 81. Residents Affected - Many Findings include: The facility's Legionella water management program was reviewed with Maintenance Staff (MS) #73 on 03/28/19. Review of the plan revealed the facility was monitoring the chlorine level in facility water supply in select resident room, and water temperatures at the point of delivery within the facility. The monthly total chlorine and total free chlorine reading of the water in the facility was 0.0 on 02/14/19 and on 03/04/19, and when checked with MS #73 at 10:37 A.M. The chlorine level inspection sheet the facility was using did not specify what the desired/acceptable parameter for chlorine levels in the facility water supply were or what actions to take if they fell below an acceptable range. The water temperature monitoring log indicated the control limit for the water was 105 degrees Fahrenheit (F) to 120 F, that water temperatures were tested weekly was maintained in this range. The water temperature log did not specify where the water temperatures were taken, i.e. at the hot water heater or the point of delivery. However, while the control limit for hot water was consistent with safety requirements at the point of delivery, it was not sufficient for the destruction of Legionella bacteria. MS #73 reviewed the facility's current water management plan and affirmed the facility water registered 0.0 ppm of chlorine, and that the goal was to maintain water temperatures in between 105 F and 120 F. MS #73 was then queried about the temperature of the water in the hot water heater, and a tour of the facility was taken at 03/28/19 at 11:17 A.M. to observe the hot water heaters. There was a temperature gauge on the C Hall hot water heater for the C Hall, central kitchen, and laundry, indicated the temperature of the water in the heater was 125 F. The remainder of the hot water heaters in the building supplying resident rooms in A, B, D, E, and F halls did hot have temperature gauges. MS #73 reported he did not monitor the temperature of the water in the water heaters, only at the point to delivery. The facility confirmed this had a potential to affect all 81 residents residing in the facility. Review of the Policy and Procedure titled Legionella specified the facility would identify control measures and monitoring such as water temperatures, sanitizer levels, and disinfectant levels. The procedure included measuring of water quality throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring, and maintaining appropriate temperature levels for water heaters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 If continuation sheet Page 10 of 10