Health inspection·February 3, 2022

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was provided with the required beneficiary notice in writing and in advance of discontinuing skilled Medicare part A services. This affected one (#74) of three residents reviewed for beneficiary protection notification. The facility census was 84. Residents Affected - Few Findings include: Review of the Resident #74's chart revealed Resident #74 admitted to the facility on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, weakness, cardiomyopathy, shortness of breath, constipation, hypertension, anemia, anxiety disorder, major depressive disorder and hyperlipidemia. Review of Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #74 required supervision with bed mobility, transfers, eating, toileting, and personal hygiene. Resident #74 required limited assistance with dressing. Review of Resident #74's chart revealed Resident #74 was admitted to the facility on [DATE] under Medicare Part A services. Resident #74's last covered day of Medicare Part A services was 01/13/22. Review of Resident #74's Notice of Medicare Non Coverage (NOMNC) dated 01/12/22 revealed Resident #74's Medicare Part A services would end on 01/13/22. Further review of the NOMNC revealed verbal consent was received on 01/12/22 and the NOMNC was completed by Social Services #65 and witnessed by Registered Nurse (RN) #18. The form did not include the name of the person that provided the verbal consent. Review of Resident #74's Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNFABN) dated 01/12/22 revealed Resident #74 may have to pay out of pocket for skilled services beginning on 01/13/22. Further review of the SNFABN revealed verbal consent was received on 01/12/22 and the SNFABN was completed by Social Services #65 and witnessed by Registered Nurse (RN) #18. The form did not include the name of the person that provided the verbal consent. Interview on 02/01/22 at 2:00 P.M. with Manager of Clinical Services #300 verified Resident #74's NOMNC and SNFABN was only provided one day prior to Resident #74's discharge from Medicare Part A skilled services. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on beneficiary notices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure privacy curtains were clean and free of stains and substances. This affected two (#17 and #09) of 24 residents reviewed for privacy curtains. The facility census was 84. Findings include: 1. Review of the Resident #9's chart revealed Resident #09 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, human immunodeficiency virus disease, shortness of breath, hyperlipidemia, insomnia, other irritable bowel syndrome, other muscle spasms and unspecified abdominal pain. Review of Resident #09's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #9 required extensive with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #09 required supervision assistance with eating. Interview with Resident #09 on 01/31/22 at 1:40 P.M. revealed Resident #09 was concerned that the facility did not change his privacy curtain. Observation of Resident #09's privacy curtain on 01/31/22 at 1:40 P.M. revealed Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Observation of Resident #09's privacy curtain on 02/02/22 at 1:36 P.M. revealed Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Interview with the Director of Nursing (DON) on 02/02/22 at 1:36 P.M. verified Resident #09's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. 2. Review of the Resident #17's chart revealed Resident #17 admitted to the facility on [DATE] with diagnoses including hypertension, anemia, constipation, muscle weakness, alcohol abuse, and abnormal posture. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #17 required extensive assistance with bed mobility, eating, and toileting. Resident #17 required total dependence with transfers, dressing, and personal hygiene. Observation of Resident #17's privacy curtain on 01/31/22 at 12:53 P.M. revealed Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Observation of Resident #17's privacy curtain on 02/02/22 at 1:36 P.M. revealed Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. Interview with the Director of Nursing (DON) on 02/02/22 at 1:36 P.M. verified Resident #17's privacy curtain had multiple brown splatters and a smeared brown substance on the curtain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 0584 Level of Harm - Minimal harm or potential for actual harm Email correspondence with Assistant Administrator #117 on 02/03/22 at 12:56 P.M. revealed the facility did not have policy on cleaning privacy curtains. This certification deficiency substantiates OH00113101. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure vision and hearing impairment was accurately coded on the Minimum Data Set (MDS) assessment. This affected two resident (#14 and #22) out of 19 residents reviewed for accuracy of assessments. The facility census was 84. Findings include: 1. Review of the Resident #14's chart revealed Resident #14 admitted to the facility on [DATE] with diagnoses including other injury of unspecified body region, presence of left artificial knee joint, arthritis due to other bacteria, cellulitis of left lower limb, essential hypertension, pain in left leg, retinal artery branch occlusion, low tension glaucoma, unqualified visual loss both eyes, myopia, anemia and carpal tunnel syndrome right upper limb. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #14 required extensive with transfers, bed mobility, dressing, toileting, and personal hygiene. Resident #14 also required supervision with eating and Resident #14 had adequate vision with no devices. Review of Resident #14's vision care plan dated 08/21/19 revealed Resident #14 had impaired vision related to glaucoma and wearing glasses. Review of Resident #14's optometry vision dated 08/21/21 revealed Resident #14 had glaucoma in both eyes. Resident #14 was to follow up with ophthalmology. Review of Resident #14's ophthalmology clinic note dated 12/20/21 revealed Resident #14 had intraocular pressure. Interview with Resident #14 on 01/31/22 at 9:47 A.M. revealed she had issues with vision with an upcoming vision surgery that was supposed to be schedule. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #14's impaired vision was not coded accurately on the MDS. 2. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia with behavioral disturbance, transient cerebral ischemic attack, pain in right knee, major depressive disorder, muscle weakness, atrial fibrillation, and tremors. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 had adequate hearing with no hearing aid or hearing appliances used. Review of Resident #22's care plan revealed Resident #22 did not have a care plan for hearing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #22's audiology visit dated 09/21/20 revealed resident complained of hearing loss. Resident #22 was interested in trialing hearing aids and hearing aids were recommended in the ear. Resident #22 had mild to severe sensorineural hearing loss in the right ear and a moderate to severe sensorineural hearing loss in the left ear. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #22's impaired hearing was not coded accurately on the MDS. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on coding the MDS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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** 2. Resident #83 was admitted to the facility originally on 03/26/21 and readmitted on [DATE]. Her diagnoses included but were not limited to epilepsy. She had a quarterly Minimum Data Set (MDS) assessment completed on 01/20/22. She was assessed as having memory problems. She needed limited assist of one staff for bed mobility, and transfer. She did not walk. She needed extensive assist of one staff for locomotion, dressing, toilet use, personal hygiene, and bathing. She was frequently incontinent of bowel and bladder. She had a significant weight gain and was on a physician-prescribed weight-gain regimen. She was at risk for pressure ulcers and had no unhealed pressure ulcers. Review of the clinical record revealed she was ordered Keppra 500 milligrams (mg) by mouth daily for seizures. Further review revealed she was hospitalized on [DATE] and 12/31/21 after having a seizure. Review of Resident #83's care plans revealed she did not have a care plan for seizure activity. An interview was conducted with the MDS Nurse #93 on 02/02/22 at 2:15 P.M. She verified Resident #83 did not have a care plan for seizures. Based on interview and record review, the facility failed to develop a care plan to address a resident's hearing impairment and seizures. This affected two resident (#22 and #83) out of 19 residents reviewed for accuracy of care planning. The facility census was 84. Findings include: 1. Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia with behavioral disturbance, transient cerebral ischemic attack, pain in right knee, major depressive disorder, muscle weakness, atrial fibrillation, and tremors. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 had adequate hearing with no hearing aid or hearing appliances used. Review of Resident #22's care plan revealed Resident #22 did not have a care plan for hearing. Review of Resident #22's audiology visit dated 09/21/20 revealed resident complained of hearing loss. Resident #22 was interested in trialing hearing aids and hearing aids were recommended in the ear. Resident #22 had mild to severe sensorineural hearing loss in the right ear and a moderate to severe sensorineural hearing loss in the left ear. Interview with Licensed Practical Nurse (LPN) #93 on 02/02/22 11:04 A.M. verified Resident #22's impaired hearing was addressed on Resident #22's care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on care planning. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 staff interview, the facility failed to a resident's smoking care plan was revised. This affected one (#09) of 19 residents reviewed for privacy care plans. The facility census was 84. Findings include: Review of the Resident #09's chart revealed Resident #9 admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, human immunodeficiency virus disease, shortness of breath, hyperlipidemia, insomnia, other irritable bowel syndrome, other muscle spasms and unspecified abdominal pain. Review of Resident #09's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #09 required extensive with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #09 required supervision assistance with eating. Review of Resident #09's smoking assessment dated [DATE] revealed Resident #09 needed a smoking holder attached to this wheelchair. Review of Resident #09's smoking assessment dated [DATE] revealed Resident #09 needed a smoking holder attached to this wheelchair. Review of Resident #09's smoking care plan dated 11/21/17 revealed resident was at risk for health risks due to smoking. Interventions included a smoking apron to be worn when smoking. Further review of Resident #09's smoking care plan revealed resident's smoking holder to his wheelchair was not listed on the care plan. Observation of Resident #09 smoking on 02/01/22 at 1:38 P.M. revealed Resident #09 was not wearing a smoking apron but Resident #09 was using a smoking holder that was attached to his wheelchair. Interview on 02/01/22 at 2:00 P.M. with Manager of Clinical Services #300 verified Resident #09's care plan was not revised to reflect Resident #09's updated smoking assessment that did not require a smoking apron. Manager of Clinical Services #300 also verified Resident #09's smoking care plan was not revised to address Resident #09's smoking holder. Telephone interview with Manager of Clinical Services #300 on 02/03/22 at 10:56 A.M. revealed the facility did not have a policy on care planning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 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 366251 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Home at Hearthstone, The 8028 Hamilton Avenue Cincinnati, OH 45231 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 interview and record review, the facility failed to address a resident's drug regimen review timely. This affected one resident (#22) out of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the Resident #22's chart revealed Resident #22 admitted to the facility on [DATE] with diagnoses including congestive heart failure, vascular dementia with behavioral disturbance, transient cerebral ischemic attack, pain in right knee, major depressive disorder, muscle weakness, atrial fibrillation, and tremors. Review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #22 required extensive assistance with bed mobility and dressing. Resident #22 required supervision with transfers, eating, and toileting and limited assistance with personal hygiene. Resident #22 received antidepressant, anticoagulant, diuretic and opioids during the MDS review period. Review of Resident #22's consultant pharmacist recommendation dated 10/08/21 revealed Resident #22 was receiving antidepressant therapy with sertraline 175 milligrams (mgs) daily. A dose reduction was recommended. Resident #22's physician provided a response that stated Resident #22 was tolerating the medication well and a dose reduction would worsen symptoms on 11/03/21. Interview on 02/22/22 at 1:58 P.M. with Manager of Clinical Services #300 verified Resident #22's pharmacy recommendation was made on 10/08/21 and it was not addressed by the physician until 11/03/21. Review of the facility's medication regimen review dated 11/28/17 revealed the facility designee or physician will respond to the recommendations in a timely manner upon the completion of the monthly regimen review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 If continuation sheet Page 10 of 10