Inspection·May 23, 2022

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 interview, the facility failed to obtain a laboratory value as ordered by the physician for a resident. This affected one (Resident #49) of five residents reviewed for unnecessary medications. The facility census was 91. Residents Affected - Few Findings include: Review of Resident #49's medical record revealed an admission dated of 10/07/20. Diagnoses included hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was assessed as being cognitively intact. Review of a pharmacy recommendation dated 02/09/22 revealed Resident #49 was currently on Levothyroxine 25 micrograms (mcg) daily and there was no evidence of a thyroid stimulating hormone (TSH) (laboratory value) in Resident #49's chart. A recommendation of a drawing a TSH now and at least yearly after was made. The physician signed and agreed with the recommendation on 02/17/22. Review of the physician orders dated 02/17/22 revealed an order for a TSH laboratory value in the A.M. and in three months. Further review of Resident #49's medical record revealed no documentation of a TSH level being obtained from 02/18/22 to 05/17/22. During an interview on 05/18/22 at 1:43 P.M., Corporate Nurse (CN) #250 confirmed a TSH level was not obtained on 02/18/22 or after for Resident #49. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 If continuation sheet Page 2 of 5 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 05/23/2022 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, and policy review, the facility failed to ensure hand hygiene was completed during dining services and failed to ensure gloves were changed and hand hygiene was completed during a wound dressing change. This affected three (#57, #22 and #79) of 20 residents who ate in their room on 05/16/22 during lunch and affected one (#82) of two residents reviewed for dressing changes during the annual survey. The facility census was 91. Residents Affected - Some Findings include: 1. Medical record review for Resident #82 revealed an admission of 07/30/20. Diagnoses included sepsis unspecified organism, coronary artery disease, renal insufficiency neurogenic bladder, and wound infection. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact. Review of the physician's orders for Resident #82 dated 05/17/22 revealed to cleanse the area to the sacrum with normal saline, pat dry, apply one-fourth strength Dakins soaked gauze to wound, cover with ABD pads (a pad used for high absorbency) and don't use tape. Observation of a dressing change for Resident #82 on 05/18/22 at 1:55 P.M. with Licensed Practical Nurse (LPN) #115 revealed she washed her hands and put on gloves, removed the ABD pad and the dressing inside of the wound, sprayed wound cleanser on the wound, and cleaned the wound. LPN #115 proceeded to take the Dakins solution and placed it into the package that had a 4 X 4 in the package. LPN #115 did not change her gloves and took her right gloved hand and pulled out the 4 X 4, folded it up and placed it into the wound and removed her gloves and placed a clean pair of gloves onto her hands and placed a clean ABD pad on the wound. Interview with LPN #115 on 05/18/22 at 2:08 P.M. confirmed she should have changed her gloves and washed her hands after cleansing the wound and placed on new gloves to place the clean dressing into the wound. 2. Observation on 05/16/22 at 12:19 P.M. revealed State Tested Nursing Aide (STNA) #135 went into Resident #57's room and dropped off a lunch tray and came out of the room and didn't sanitize her hands. She continued to enter Resident #22's room, which had a sign on the door for contact isolation, dropped off a lunch tray and touched the tray table and a wheelchair with her right hand on the way out of the room. She continued to take both of her hands and pull trays out of the dining cart and took a lunch tray into Resident #79 and didn't wash or sanitize her hands upon leaving this resident's room. Interview with STNA #135 on 05/16/22 at 12:30 P.M. confirmed she didn't wash or sanitize her hands in-between rooms especially the isolation room and confirmed she should have performed hand hygiene. Review of the facility's policy titled Infection Prevention and Control Program dated 08/10/18 revealed it was the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. All staff shall perform hand hygiene between resident contacts and after handling contaminated objects. Gloves are changed and hand (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 If continuation sheet Page 3 of 5 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 05/23/2022 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 hygiene is performed before moving from a contaminated body site to a clean body site during resident care. 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 4 of 5 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 05/23/2022 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 0881 Implement a program that monitors antibiotic use. 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, record review, staff interview, and review of the facility's used clinical references, the facility failed to have justification for use of an antibiotic to treat a urinary tract infection for Resident #30. This affected one (Resident #30) of five residents reviewed for unnecessary medications. The facility census was 91. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed an admission date of 01/31/16. Diagnoses included dementia, schizophrenia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Review of Resident #30's physician orders dated 03/19/22 revealed an order for Ciprofloxacin hydrochloride (HCl) (antibiotic) 250 milligram (mg) two times a days for a UTI for seven days. Review of the medication administration records (MARs) revealed Ciprofloxacin was administered as ordered starting on 03/19/22. Further review of Resident #30's medical record revealed no documentation of a urine culture being obtained prior to the use of Ciprofloxacin in March 2022. There was no documentation of any physician recommendation to continue Ciprofloxacin without obtaining urine culture results. There was no evidence of Resident #30 having a fever or any painful urination. Review of the facility's infection control log revealed on 03/19/22, Resident #30 was noted as having a UTI. No urine culture was obtained. Resident #30 was ordered Ciprofloxacin twice a day for seven days. Review of the facility's clinical reference used for a urinary tract infection, National Health and Safety Network Urinary Tract Infection Catheter-Associated Urinary Tract Infection (CAUTI) and Non-Catheter-Associated Urinary Tract Infection (UTI) Events dated January 2022 revealed a resident that did not have an indwelling urinary catheter must have at least one of the following signs and symptoms to be considered a UTI. Fever greater than 38 celsius, suprapubic tenderness, costoverbal angel pain of tenderness, urinary frequency, urinary urgency, or dysuria. The resident must also have a urine culture with has a urine culture with no more than two species of organisms identified of at least one of which is a bacterium of greater than 100,000 colony-forming units per milliliter (CFU/ml). During an interview on 05/18/22 at 3:30 P.M., Corporate Nurse (CN) #250 confirmed there was not a justified use of Ciprofloxacin for UTI for Resident #30 on 03/19/22. CN #250 confirmed there was not any documentation of Resident #30 meeting the criteria for having an UTI. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366208 If continuation sheet Page 5 of 5