Inspection·October 5, 2021

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During interview on 09/30/21 at 2:30 P.M., the DON verified the chart lacked evidence of physician notification of abnormal blood pressure readings on 09/01/21 and 09/29/21 and abnormal blood sugar levels on 09/10/21, 09/15/21, 09/21/21, and 09/25/21. Review of the facility policy titled Change in Condition, updated 11/17/20, revealed the physician should immediately be notified of clinical complications and the notification should be documented in the medical record. Event ID: Facility ID: 366232 If continuation sheet Page 2 of 7 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure there was ongoing communication, coordination and collaboration between the facility and the dialysis center. This affected one (Resident #35) of one resident who received dialysis in the facility. The census was 40. Residents Affected - Few Findings include: Review of medical record for Resident #35 revealed an original admission date of 07/14/21. Additional admissions /discharges included resident was discharged with a return not anticipated on 07/21/21 and readmitted on [DATE]. Diagnosis included hypertensive emergency, hypertension, diabetes mellitus, chronic kidney disease with end stage renal disease with dependence on renal dialysis and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 08/20/21, revealed Resident #35 was cognitively intact, had no behaviors, did not reject care, was a one-person physical assist, required limited assistance and/or supervision for activities of daily living and received dialysis. Review of plan of care for Resident #35 reveled resident was dependent on renal dialysis related to end stage renal failure and risk for adverse effects of medications due to diuretic usage. Interventions included monitor document any signs of renal insufficiency, obtain vital signs and weight per protocol and report any significant changes and medicate as ordered per physician's orders. Review of physician orders for Resident #35 dated 07/14/21 revealed resident was ordered to receive hemodialysis on Tuesdays, Thursdays, and Saturdays at an off-site location. Review of electronic medical record and paper medical record for Resident #35 revealed no documented evidence of ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. During interview on 09/29/21 at 4:00 P.M., the Director of Nursing (DON) stated the facility had no documented communication or collaboration notes with dialysis facility. During telephone interview 09/29/21 at 4:23 P.M. with dialysis center staff, they stated the facility called them an hour ago and requested all information from resident's admission on [DATE]. The dialysis center verified there was no documented communication between them and the facility. Review of the facility policy titled Dialysis Policy, dated 09/25/20, revealed the facility would assure resident received care and services for the provision of hemodialysis consistent with profession standards of practice including the ongoing assessment of the resident condition and monitoring for complications before and after dialysis treatments received and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366232 If continuation sheet Page 3 of 7 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During observation of medication administration on 09/29/21 at 812 A.M., LPN #56 applied hand sanitizer and started to prepare medications for Resident #195. LPN #56 used her keys to open the medication cart, touched numerous areas on the cart, touched the computer and computer mouse, touched her face mask, her face shield, and her eyeglasses before she started to prepare medications, LPN #56 prepped three medications by opening the foil/paper packages and pouring them into a medicine cup. LPN #56 opened the top drawer, retrieved a bottle of multivitamins, poured a tablet in the lid, used her left thumb to secure the pill in the lid and then dumped the multivitamin in the medication cup with other medications. LPN #56 opened the drawer, retrieved a Mobic 7.5 milligram (mg) package, and laid it on top of the medication cart. When LPN #56 completed preparing all medications for Resident #159, LPN #56 placed the packaged Mobic in the medicine cups with other pills. LPN #56 stated she wanted to ask Resident #159 if she wanted the medication prior to opening the pill. Observation at 8:20 A.M. revealed LPN #56 entered Resident #159's room, removed the package of Mobic 7.5 from the medicine cup and handed the medicine cup to Resident #159. Observation at 8:21 A.M. revealed Resident #159 took the medications in the medicine cup. Residents Affected - Many During interview with LPN #56 on 09/29/21 at 8:28 A.M. verified she touched numerous items then touched Resident #159's multivitamin with her fingers. LPN #56 also verified she placed the medication package for Mobic in with the other medications. This deficiency substantiates Complaint Number OH00111057. Based on record review, observation, interview, policy review, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19, failed to ensure staff wore personal protective equipment (PPE) in the facility to prevent the potential spread of Coronavirus (COVID-19), and failed to ensure staff administered medications utilizing proper infection control practices to prevent the potential spread of infectious disease. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. Interview on 09/28/21 at 10:51, the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366232 If continuation sheet Page 4 of 7 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many initiated immediately because they did not consider the one positive employee test to be an outbreak. DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. DON verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. 2. Observation on 09/27/21 at 12:48 P.M. revealed Resident #22 in her room with two visitors on the B-wing of the facility. Observation on 09/27/21 at 12:35 P.M. revealed Resident #30's wife visiting Resident #30 in his room on the [NAME] wing. During observation of [NAME] wing on 09/27/21 at 12:00 P.M., two visitors entered Resident #2's room. Resident #2 was in quarantine status due to being a new admission and being unvaccinated. The visitor exited Resident #2's room with a lunch tray and placed it at the nursing station. The visitor entered the resident's room again with only a surgical mask in place. Interview with LPN #151 at same time verified Resident #2 had two visitors in his room and also indicated visitors should utilize appropriate PPE when visiting a resident on quarantine. During observation of the [NAME] wing on 09/29/21 at 1:00 P.M., a visitor was in Resident #147's room. Resident #147 was in quarantine status due to being new admission and being unvaccinated. The visitor was wearing only a surgical mask. Interview with Resident #147's visitor at the time of the observation revealed she had visited daily since resident was admitted on [DATE]. During observation on 09/28/21 at 11:47 A.M., a visitor was observed standing next to Resident #95 in the dining room. Concurrent interview with the visitor revealed she was Resident #95, who had recently admitted to the facility and was unaware of any restriction on visitation. During interview on 09/28/21 at 10:51 A.M., the DON stated visitation had not been suspended following LPN #82 testing positive on 09/24/21 and was not suspended at the time of the survey. Review of an email dated 09/29/21 at 9:28 A.M., the DON stated the facility had 91 visitors between 09/24/21 at 6:30 P.M. and 09/29/21 at 10:00 A.M. Review of the CMS QSO-20-39-NH-revised, dated 04/27/21, revealed, when a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation on the affected unit until at least one round of facility-wide testing was completed and no new cases were discovered. Additionally, the facility should suspend visitation on the affected units until the facility meets the criteria to discontinue outbreak testing which included 14 days of negative testing for HCP and residents. 3. Observation on 09/28/21 at 11:44 A.M. revealed Residents #28 and #95 seated at a table in the dining room. Dining Services Representative (DSR) #29 was observed wearing a surgical mask underneath his chin and delivered food to Resident #95 and briefly conversed with Residents #95 and #28. Interview on 09/28/21 at 11:46 A.M. DSR #29 verified his surgical mask was down below his chin, not covering his nose and mouth, when he delivered food to Resident #95 and conversed with Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366232 If continuation sheet Page 5 of 7 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber 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 #95 and #28. Level of Harm - Minimal harm or potential for actual harm Review of the facility's staff vaccination log revealed DSR #29 was fully vaccinated. Residents Affected - Many Review of the facility policy titled, COVID-19 Preparedness and Response Plan, last updated 09/21/21 revealed employees are required to wear a mask in all patient and resident-facing areas and employees should never remove their mask in the presence of a resident. Review of the CDC guidelines titled, Infection Control Guidance, updated 09/10/21, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) revealed fully vaccinated health care personnel should wear source control (mask covering a person's mouth and nose to prevent spread of respiratory secretions when they are breathing or talking) when they are in areas of the healthcare facility where they could encounter patients (including cafeteria and common halls/corridors). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366232 If continuation sheet Page 6 of 7 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 366232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westover Retirement Community 855 Stahlheber 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19. This had the potential to affect all 40 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. During interview on 09/28/21 at 10:51 A.M., the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not initiated immediately because they did not consider the one positive employee test to be an outbreak. The DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. She verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. This deficiency substantiates Complaint Number OH00111057. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366232 If continuation sheet Page 7 of 7