Inspection·July 25, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleeping too much, tired, poor appetite, easily annoyed/short-tempered, displays agitation, physical behaviors, paces, hoarding, and yelling. 3. Review of the Resident #65's progress notes, dated 07/13/24 at 9:57 AM documented Resident #65 was being yelled at by another resident, who swung their left hand at Resident #65. After separating the residents, a slight scratch was noted on Resident #65's left cheek bone. Review of Resident #25's progress notes, dated 07/13/24 at 9:23 AM, stated Resident #25 was seated at a dining room table when another resident approached them. Resident #25 started yelling and hit the other resident with their left hand. Review of the document titled General Investigation of Incident, signed by the Director of Nursing (DON) on 07/15/24, revealed that on 07/13/24, a physical altercation occurred between Resident #25 and Resident #65. Resident #25 was sitting at a dining room table when Resident #65 bumped Resident #65's wheelchair. Resident #25 started yelling and hit Resident #65 on their left cheek. The physician and responsible parties were notified; however, there was no documentation to indicate the facility reported the incident to the state survey agency. During an interview on 07/23/24 at 3:15 PM, Licensed Practical Nurse (LPN) #6 stated the DON was notified of the incident involving Resident #25 and Resident #65 that occurred the week prior. During an interview on 07/25/24 at 12:51 PM, DON #3 stated any occurrence between residents should be reported immediately after ensuring the safety of the residents. She stated incidents resulting in serious injury, falls with hospitalization, anything fatal to a resident, any injury or medication error resulting in death, any allegation of abuse, or unknown injuries were all incidents that needed to be reported. She stated the incidents between Resident #25 and Resident #65 in July 2024 did not meet the reporting criteria because both residents had dementia and did not recall the incident afterwards, and no major injuries were sustained by either resident; although she stated she felt there was intent when Resident #25 hit Resident #65. DON #3 stated that the Administrator was responsible for submitting reports to the state survey agency. During an interview on 07/25/24 at 5:05 PM, the Administrator stated that per guidance from the state survey agency, any incident with police involvement, serious injury, injury of unknown origin, and resident-to-resident incidents that resulted in serious physical or psychosocial injury should be reported to the state survey agency. The Administrator stated the incident on 07/13/24 did not qualify for reporting, because there was no intent to harm between the residents. Per the Administrator, Resident #65 bumped into Resident #25, and in response, Resident #25 flailed to get them away. She stated that neither resident recalled the incident and neither had any decline in function. A facility policy titled, Abuse, Neglect, Exploitation & [and] Misappropriation of Resident Property, dated 11/21/2016, indicated, E. REPORT & INVESTIGATE l. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. 2. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation or [sic] resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 If continuation sheet Page 2 of 6 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 07/25/2024 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 0609 designee of the facility and to other officials, including the State Survey Agency, in accordance with State law. 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 3 of 6 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 07/25/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to have physician orders for the use of supplemental oxygen. This affected one (Resident #57) of one resident reviewed for respiratory care. Residents Affected - Few Findings included: Review of the admission record revealed Resident #57 was admitted on [DATE]. The resident had diagnoses including chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of the physician orders revealed no order for oxygen. Review of the admission Minimum Data Set (MDS) assessment, dated 07/12/24, revealed Resident #57 had moderate cognitive impairment. Resident #57 did not have oxygen therapy on admission or while a resident during the assessments 14-day lookback period. Review of Resident #57's care plan dated 07/15/24, documented the resident had altered health maintenance related to progressive physical and mental status and diagnoses of COPD and acute respiratory failure. Interventions directed staff to administer oxygen per the physician's orders. During an observation on 07/22/24 at 9:58 AM, Resident #57 was receiving oxygen at a flow rate of 4.5 liters per minute. During a concurrent interview Resident #57 stated they never touched the oxygen flow rate setting. During an observation on 07/23/24 at 3:00 PM, Resident #57 was sitting up on the side of their bed wearing a nasal cannula with oxygen set at a flow rate of 4.5 liters per minute. During an observation on 07/24/24 at 7:30 AM, Resident #57 was lying in their bed on their back wearing a nasal cannula with oxygen set at a flow rate of 4 liters per minute. During an observation and interview on 07/24/2024 at 1:33 PM, Registered Nurse (RN) #4 went to the dining room. Resident #57 at the dining room tables wearing supplemental oxygen set at 4 liters per minute via a portable oxygen tank. RN #4 said that the resident's oxygen was set at 4 liters per minute and stated that was what she thought the resident's order for oxygen was. She said that she thought that Assistant Director of Nursing (ADON) #5 had applied the resident's oxygen earlier that day. RN #4 reviewed Resident #57's orders and said she was unable to find an order for the resident's oxygen flow rate settings. She stated that she put Resident #57's oxygen on the previous day, before the resident left for dialysis, at a flow rate of 4 liters per minute. During an observation and interview on 07/24/2024 at 1:52 PM, ADON #5 checked Resident #57's oxygen flow rate and stated that it was set at 4 liters per minute. ADON #5 stated she thought the resident was supposed to receive oxygen at a flow rate of 2 liters per minute. ADON #5 stated Resident #57's supplemental oxygen was set at a flow rate of 4 liters per minute this morning when the resident was up in their wheelchair and the flow rate was adjusted to 2 liters per minute. ADON #5 stated that the resident was known to change their supplemental oxygen flow rate settings. During a concurrent interview Resident #57 stated they did not change their supplemental oxygen flow rate settings and that they did not know how to. ADON #5 reviewed Resident #57's orders and stated that there was no order for the resident's supplemental oxygen flow rate settings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 If continuation sheet Page 4 of 6 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 07/25/2024 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 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 observation, interview, record review, and policy review, the facility failed to ensure a urinary catheter bag was not left on the floor and failed to ensure contaminated incontinence care supplies were disposed of appropriately. This affected two (Residents #54 and #21). Residents Affected - Few Findings include: 1. Review of the admission record revealed the facility admitted Resident #54 on 07/14/23. Diagnoses included obstructive and reflux uropathy. Review of the annual Minimum Data Set (MDS) assessment, dated 06/08/24, revealed Resident #54 had intact cognition. The resident had an indwelling catheter. During an observation on 07/22/24 at 10:37 AM, Resident #54 was sitting up on the side of their bed with the urinary catheter bag lying on the floor. During an observation on 07/22/24 at 10:40 AM , a State Tested Nurse Aide (STNA) entered the room to answer the call light and exited the room without removing the catheter bag from the floor. The STNA returned at 10:42 AM and again left without taking the catheter bag off the floor. During observations 07/22/24 at 10:48 AM, 11:14 AM and 11:46 AM, Resident #54's urinary catheter bag remained on the floor. During an observation on 07/22/24 at 11:48 AM, STNA #20 entered Resident #54's room, washed her hands, told the resident she would be back, and exited the room without removing the urinary catheter bag from the floor. During an interview on 07/23/24 at 10:32 AM, STNA #20 stated that Resident #54's catheter bag should never be left on the floor due to the floor being dirty and possible cross contamination. 2. Review of the admission record revealed the facility admitted Resident #21 on 05/24/23. The resident had diagnoses including multiple sclerosis, hemiplegia and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (stroke), and an overactive bladder. Review of the quarterly MDS, dated [DATE], revealed Resident #21 had intact cognition. Resident #21 required substantial to maximal assistance with toilet hygiene, was always incontinent of urine, and was frequently incontinent of bowel. Resident #21's care plan initiated on 05/25/23, documented the resident may require assistance with activities of daily living (ADL), was incontinent of bladder and bowel and required the assistance of two staff members for toileting. During an observation on 07/23/24 at 10:37 AM, a STNA #12 positioned Resident #21 in a sit-to-stand lift so that they could perform incontinence care. While providing care, STNA #12 discarded the soiled cloths directly on the floor with the resident's soiled brief. During an interview on 07/23/24 at 11:05 AM, STNA #12 stated she set the soiled brief and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 If continuation sheet Page 5 of 6 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 07/25/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few soiled incontinence supplies on the floor and bagged them after completing Resident #21's incontinence care. STNA #12 stated that was not how she was trained, and she was trained to place the soiled supplies into a bag and not on the floor. Review of the policy titled Infection Prevention and Control Program (IPCP), revised 11/28/2017, revealed it is a policy of this 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. Review of the facility policy titled Skin: Incontinence Care Protocol, revised 09/17, revealed the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. Dispose of soiled equipment and supplies in the appropriate receptacle. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366251 If continuation sheet Page 6 of 6