Inspection·December 5, 2019

F 0550 severely impaired for daily decision-making and required extensive assistance with eating. Level of Harm - Minimal harm or potential for actual harm On 12/02/19 between 11:48 A.M. and 12:18 P.M., observation revealed three residents, including Resident #11, were seated at a table in the 100/200 hall dining room. The two other residents were served their lunch meal at 11:48 A.M. and CNA #105 sat between the residents and provided assistance/cueing. Resident #11 was sitting at the table and was not served her meal until 12:18 P.M Residents Affected - Few On 12/03/19 at 3:15 P.M., interview with Registered Nurse #100 verified resident dignity would not be maintained if residents were observed eating, non-finger foods, with their fingers and/or not being served at the same time when sitting at the same table. 3. Medical record review revealed Resident #8 was admitted on [DATE] with diagnoses including neurogenic bladder and bladder obstruction. Review of the Physician Orders dated 02/21/19 revealed an order for an indwelling urinary catheter. On 12/02/19 at 11:24 A.M. and 3:18 P.M., observation revealed dark, yellow urine in the resident's urinary catheter drainage bag hanging from his bed frame. The uncovered drainage bag was observed from the hallway. On 12/03/19 at 10:25 A.M., observation revealed Resident #8's urinary drainage bag was uncovered and contained yellow urine with sediment. Interview with CNA #104 at the time of the observation verified the resident catheter bag was not covered. Review of the care plan: Alteration in Elimination dated 09/06/19 revealed interventions to cover the catheter drainage bag when up to promote privacy. On 12/03/19 at 10:37 A.M., interview with LPN #103 stated urinary drainage bags were covered when out of the room to maintain dignity and verified if someone was able to see the urine in the collection bag from the hallway, the resident's dignity would not be maintained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 2 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure advance directive information was consistently documented between medical record/data sources. This affected two residents (Resident's #13 and #47) of 24 residents records reviewed. Findings included: 1. Record review revealed Resident #47 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including low back pain, history of falling, malignant neoplasm of the bladder, dysphagia, prediabetes, diverticulitis, gastro-esophageal reflux, dementia, acute kidney failure, Parkinson disease, malignant neoplasm of the skin, hypertension, cognitive communication, anemia, and hypercholesterolemia. Review of Resident #47's paper record revealed a signed code status indicating the resident requested not to be resuscitated and comfort care-Arrest (DNRCC-A) only, however, on the outside of the chart (on the stem of the chart) indicated the resident was a full code. Review of Resident #47's current electronic orders dated 11/2019 revealed the resident had two code status orders. One was a full code and the other was DNRCC-A. Review of Resident #47's vital parameter plan of care dated 11/13/19 revealed the resident was a full code. Interview on 12/02/19 at 2:32 P.M., with Director of Nursing (DON) confirmed there was two current code status orders. One was for a full code and the other was for a DNRCC-A. Interview on 12/02/19 at 2:35 P.M., with Registered Nurse (RN) #9 confirmed the code status on the stem of the chart indicated the resident code status was full code, however, the code status in the electronic medical record indicated the resident's code status was DNRCC-A. Review of resident rights and Advanced Directives undated revealed the facility policy was to support and facilitate a resident's rights to request, refuse and /or discontinue medical or surgical treatments and to formulate an advance directive. On admission, the facility would determine if the resident had executed an advance directive, and if not, determine whether the resident would like to formulate and advance directive. 2. Record review revealed Resident #13 was admitted on [DATE] with diagnoses including but not limited to alzheimers, dementia, hypertension, osteoarthritis, hyperlipidemia, spinal stenosis, and heart failure. Resident #13's physician orders in the electronic medical system, dated 06/02/15, revealed she was ordered do not resuscitate comfort care - arrest (DNRCC-A) for her advanced directives. Resident #13's DNR Order Form, dated 09/27/19, revealed the resident chose do no resuscitate comfort care (DNRCC) as her advanced directive. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 3 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0578 Interview on 12/02/19 at 3:42 P.M. with Registered Nurse (RN) #36 confirmed Resident #13's had an order for DNRCC-A although the DNR Order Form indicated DNRCC. 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: 366268 If continuation sheet Page 4 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 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, beneficiary notification review, policy review and interview, the facility failed to provide residents with required information regarding options of continuation of skilled services. This affected two (Resident #34 and #71) of three residents reviewed for beneficiary notices. Residents Affected - Few Findings include: 1. Record review revealed Resident #34 was admitted on [DATE] with diagnoses including hypertension and muscle weakness. Review of the SNF (skilled nursing facility) Beneficiary Protection Notification Review dated 08/08/19 revealed current skilled services were to end on 08/07/19; however, there was no evidence of what skilled services were ending. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) dated 08/08/19 revealed the resident wanted the care listed above and could not appeal because MCR would not be billed. The services listed were for long term care services with a daily room rate of $271.00. There was no evidence the facility provided the resident with information regarding the cost to continue skilled services if the resident chose additional skilled care. 2. Record review revealed Resident #71 was admitted on [DATE] with diagnoses including pneumonia, cerebrovascular accident and hemiplegia. Review of the SNF Beneficiary Protection Notification Review dated 07/15/19 revealed current services were to end on 07/17/19. Review of the Notice of Medicare Non-Coverage revealed no evidence of what services the resident was receiving. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) dated 07/18/19 revealed the resident wanted the care listed above and could not appeal because MCR would not be billed. The services listed were for long term care services with a daily room rate of $470.00. There was no evidence the facility provided the resident with information regarding the cost to continue skilled services if the resident chose additional skilled care. Review of the undated policy: Advanced Beneficiary Notices revealed the facility was to inform Medicare beneficiaries of potential liability of payments. On 12/04/19 at 9:05 A.M., interview with Business Office Manager #106 verified Residents #34 and #71's beneficiary notifications were not accurate, was not provided to the resident within the required timeframe, did not list the type of skilled services being cut from and did not indicate cost of skilled therapy if resident wanted more services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 5 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure eye glasses were clean for residents requiring assistance. This affected one (Resident #61) of three residents reviewed for communication/sensory. Residents Affected - Few Findings include: Medical record review revealed Resident #61 was admitted on [DATE] with diagnoses including diabetes mellitus and cerebral vascular accident (CVA) with left hemiplegia (paralysis on one side of the body). Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #61 was cognitively intact for daily decision-making, had adequate vision with the use of glasses and he required extensive assist with personal hygiene. Review of the undated Resident Care Guide revealed Resident #61 wore glasses. Review of the care plan: ADL Self-Care Deficit due to CVA with left hemiplegia dated 10/14/19 revealed Resident #61 required extensive assistance with personal hygiene. Review of the record revealed no care plan addressing the resident's need to wear glasses or cleaning them. On 12/02/19 at 10:52 A.M., observation revealed Resident #61's eyeglasses were dirty and smudged. On 12/03/19 at 9:42 A.M., observation revealed Resident #61 was sitting at the nurses station in wheelchair and was wearing glasses. The resident's glasses were observed to be smudged and dirty. Resident #61 stated his glasses were dirty, he required assistance from staff to clean them and he had an additional pair of glasses in his room. On 12/03/19 at 9:43 A.M., interview with Licensed Practical Nurse (LPN) #103 verified Resident #61's glasses were dirty and stated the resident required staff assistance with care including cleaning his glasses. LPN #103 stated staff should be cleaning the resident's glasses when the resident gets up in the morning and as needed. On 12/03/19 at 10:26 A.M., interview with Certified Nursing Assistant #104 stated staff cleaned the resident's glasses when providing care. On 12/03/19 at 3:12 P.M., interview with Registered Nurse #100 verified nursing was responsible for cleaning the resident's glasses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 6 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to assist and ensure supports were in place as recommended to maintain positioning. This affected one resident (Resident #32) observed in one of three dining rooms. Residents Affected - Few Findings include: Medical record review revealed Resident #32 was admitted on [DATE] with diagnoses including Alzheimer's disease and open reduction internal fixation of the left hip. Review of the OT (occupational therapy) Discharge summary dated [DATE] revealed recommendations including the use of a specialized wheelchair with a right lateral support, a right padded arm rest, and right padded leg box. Review of the OT Long-Term Goals dated 07/15/19 included Resident #32 was to demonstrate midline sitting after set-up in a reclining wheelchair with the addition of a right lateral support and potentially a left lateral support to facilitate the ability to perform functional tasks at wheelchair level. Review of the care plan: Musculoskeletal System revised 10/18/19 revealed the need for monitoring due to the resident was non-ambulatory and to assess muscle for strength in flexion/extension and abnormal movement, spasticity and tremors. Review of the care plans revealed no evidence the resident required assist with positioning or required any supports for positioning. On 12/02/19 between 11:59 A.M. and 12:17 P.M., observation of the lunch meal in the 100/200 hall dining room revealed Resident #32 was sitting at a table in a specialized wheelchair and was leaning to the right. The resident's armpit was resting against a padded right arm rest, her right hand was resting against the wheel and she was eating with her left hand. There was no right lateral support observed on the wheelchair. At 12:03 P.M., Licensed Practical Nurse (LPN) #101 was observed walking past Resident #32 and did not reposition Resident #32. At 12:07 P.M., the resident tried to pull herself to an upright position but was unable to and continued to lean to the right. At 12:17 P.M., Certified Nursing Assistant (CNA) #102 was observed placing her arms under the resident to position her; however, once CNA #102 left the table, the resident slowly leaned back to the right without any side supports. On 12/03/19 at 2:30 P.M., interview with Rehab Director #108 stated Resident #32 was on therapy caseload for positioning due to the resident leaning in her wheelchair. Rehab Director #108 stated the resident was to have a right lateral support and arm rest on her wheelchair to maintain appropriate positioning in the wheelchair. At the time of the interview, Rehab Director #108 verified there was no right lateral support on the resident's wheelchair. Rehab Director #108 also stated Resident #32 should not be leaning and it was her expectation that staff would notify therapy of this to address positioning concerns. On 12/03/19 at 3:17 P.M., interview with Registered Nurse #100 verified there was no evidence the resident would require assist or lateral supports to aide in positioning to maintain proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 7 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0684 alignment. RN #100 stated she was currently working on updating the care plans and verified the care plans were not comprehensive or individualized. 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: 366268 If continuation sheet Page 8 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interview, the facility failed to ensure resident hearing aides were used. This affected one (Resident #8) of three residents reviewed for communication-sensory. Residents Affected - Few Findings include: Medical record review revealed Resident #8 was admitted on [DATE] with diagnoses including depression and diabetes mellitus. Review of the Resident Care Guide dated 11/16/18 revealed Resident #8 wore hearing aids. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #8 had adequate hearing with hearing aids. Review of the significant change MDS assessment dated [DATE] revealed the resident had moderate difficulty hearing and did not have hearing aids or other hearing appliance. Review of the Focused and Comprehensive assessment dated [DATE] revealed the resident had hearing difficulty. No evidence the resident wore hearing aids. Review of the care plans: Alteration in communication related to moderate difficulty hearing dated 09/06/19 revealed interventions including to assist with hearing aid placement and maintenance. On 12/02/19 at 3:42 P.M., observation revealed Resident #8 was not wearing hearing aids. On 12/03/19 at 10:34 A.M., observation revealed Resident #8 was in bed with no hearing aids. On 12/03/19 at 10:27 A.M., interview with Certified Nurse Assistant (CNA) #104 stated she was the residents aid, has taken care of him before and the resident did not use or have a hearing aid. Observation with CNA #104 at the time of the interview verified Resident #8 was not wearing hearing aids. On 12/03/19 at 11:01 A.M., interview with Licensed Practical Nurse (LPN) #103 stated she was Resident #8's nurse and he did not use or wear hearing aids. On 12/03/19 at 11:19 A.M., interview with Registered Nurse (RN) #100 verified the significant change MDS assessment indicated a decline in hearing and no hearing aids were used during the assessment. On 12/03/19 at 3:43 P.M., interview with Licensed Social Worker (LSW) #107 stated she located Resident #8's hearing aids in his bedside drawer and they were functional. LSW #107 stated staff should know what appliances each resident used and ensure they were used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 9 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review revealed Resident #5 was admitted on [DATE]. Diagnoses included a facility-acquired Stage III pressure ulcer (full thickness tissue loss with no bone, tendon or muscle exposed) to the right buttock. Residents Affected - Few Review of the care plan: Pressure Ulcer Right Buttock dated 06/15/19 revealed interventions included to treat as ordered and ensure pressure relief device to the bed. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident was at risk for pressure ulcer development and had a Stage III pressure ulcer. Review of the Braden assessment dated [DATE] revealed Resident #5 was not at high risk for pressure ulcers. Review of the Physician Orders dated November 2019 revealed to check the air mattress every shift and complete daily pressure ulcer dressing changes. The dressing change included to cleanse the open area with normal saline, apply barrier wipe around the wound, pack lightly with mesalt (stimulates the cleansing of heavily discharging wounds in the inflammatory phase by absorbing exudate, bacteria and necrotic material) and cover with a foam dressing. On 12/04/19 between 10:21 A.M. and 10:45 A.M. observation of Resident #5's pressure ulcer dressing change included the following: Licensed Practical Nurse (LPN) #109 gathered supplies from the treatment cart including a new package of mesalt and a pair of treatment scissors from the top drawer of the treatment cart. The scissors were laying in the drawer and were not in a sealed package. LPN #109 was observed opening the package of mesalt, used the treatment scissors to cut an approximate quarter inch strip of the mesalt, returned the mesalt to the unsealed package and placed the mesalt package back in the cart for future use. LPN #109 did not clean the treatment scissors prior to or after using them to cut the mesalt impregnated gauze. LPN #109 entered the room with the surveyor and the resident was observed laying in bed on her left side and the air mattress was deflated. The plug of the air mattress was observed to be coming out of the electrical socket and the air mattress was not on. This was verified by LPN #109 at the time of the observation and verified the bed was to be on at all times. LPN #109 placed the dressing supplies on the over bed table, washed her hands at the sink, donned gloves, closed the door to the room and positioned the trash can and table next to the bed with her gloved hands. LPN #109 removed the soiled dressing and the soiled dressing was observed to contain moderate wound drainage. LPN #109 then proceeded to cleanse the wound with normal saline, placed the quarter inch strip of mesalt in the wound and then removed her gloves and placed them in the trash bag. LPN #109 then went outside the room to get the treatment scissors out of the cart, returned to the room, closed the door, washed her hands, donned gloves and covered the wound with a foam dressing. On 12/04/19 at 10:46 A.M., interview with LPN #109 verified the treatment scissors were not cleaned before use, standard precautions and hand washing/gloving was not completed as indicated during the above observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 10 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the policy: Dressing-Clean Technique dated October 1999 revealed all dressings were to be performed using clean technique unless otherwise specified by physician. Procedures including to remove the soiled dressing and discard into a plastic bag, change gloves, clean wound with sterile normal saline solution or as specified by physician. Review of the undated policy: Standard Precautions revealed staff must use standard precautions when coming in contact with non-intact skin to reduce the risk of transmission of microorganisms from both recognized sources of infection or unrecognized sources of infection in healthcare facilities. Standard precautions included: hand washing before and after gloves are removed and gloves were to be worn when touching contaminated items. Review of the undated policy: Pressure Ulcer Prevention revealed the facility was to identify existing skin alterations, to identify risk factors, reduce risk, attempt to prevent and treat skin alterations. Based on observation, medical record review, staff interview, and policy review the facility failed to ensure pressure ulcers were assessed accurately. This affected three (Residents #5, #47, and #52) of three residents reviewed for pressure ulcers. Finding include: 1. Record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including anemia, Parkinson's disease, bladder cancer, prediabetes, and lumbar fracture. Review of Resident #47's Braden scale for predicting pressure sore risk dated 11/13/19 indicated the resident had a potential problem with friction and shearing and had inadequate nutritional intakes. Review of Resident #47's skin assessments dated 11/21/19 and 11/28/19 revealed on 11/21/19 a new area on the right inner buttocks was identified. The skin area was classified as other. The description indicated the area measure one centimeter (cm) long by 1/2 cm wide superficial open skin area. There was no evidence of a description of the wound. The treatment was to cleanse the area with saline and apply a foam dressing. On the body diagram there was a X mark on the middle of right top buttocks. On 11/28/19 the weekly skin assessment of the right inner buttocks indicated the area was still classified as other and measured 1 cm long by 1 cm wide by 0.1 millimeters (mm) depth. There was no evidence of a description of the wound except the surrounding skin was red around the wound. The area was cleansed with normal saline and a foam dressing was applied. Review of Resident #47's orders dated 11/21/19 revealed to cleanse right inner buttocks with normal saline and apply a foam dressing every seven days and as needed. Interview on 12/03/19 at 10:37 A.M. and 2:35 P.M., with the Director of Nursing (DON) revealed he was not sure what other was, but after he spoke with staff today to clarify the nurse reported the area on the right buttocks was caused from friction. The resident was noted to scoot/slide down in his chair. The DON reported the area should have been classified as a stage II pressure ulcer (partial-thickness loss of dermis). The DON verified the skin alteration assessments only included measurements of the area and there was no evidence of the assessment of the wound. Observation on 12/04/19 at 11:49 A.M., of Resident #47's skin alteration with LPN #23 and RN #7 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 11 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed an open area noted on the top outer right intergluteal cleft measuring 0.7 cm by 0.5 m and depth undetermined due to wound bed was covered with thick yellow/tan slough. Interview on 12/04/19 at 8:15 A.M. and 10:34 A.M., with Licensed Practical Nurse (LPN) #23 revealed when she changed Resident #47's right buttocks dressing this morning the wound bed was yellow, wet, moist, and soft with serosanguineous drainage noted. The LPN verified the wound was yellow yesterday also when she had to change the dressing. Interview on 12/04/19 at 10:30 A.M., with Registered Nurse (RN) #100 revealed Resident #47's skin alteration was discussed in morning meeting today and the facility had originally thought the skin alteration was in the right inner buttocks due to the description of the wound, however the diagram indicated the area was on outer aspect of the buttocks. She reported the wound had deteriorated to an unstageable (full-thickness tissue loss) according the nurse's assessment in report due to the wound bed was now covered in yellow slough. Interview on 12/04/19 at 11:49 A.M. and 1:43 P.M., with RN #7 reported she had not observed the skin alteration until today, however if the area was classified as a pressure ulcer it would be classified as an unstageable pressure ulcer. Review of the classification of tissue destruction in pressure policy, undated, revealed a pressure ulcer was a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Review of the wound assessment policy dated 03/09 revealed wound assessment was used to monitor and evaluate wound progress. The wound assessment would include site/location, size, shape, appearance, and drainage/exudate. Notify physician and family. 2. Record review revealed Resident #52 was admitted on [DATE] with diagnoses including but not limited to dementia without behavioral disturbance, abnormal posture, and congestive heart failure. Resident #52's Skin Evaluation Form dated 11/30/19 revealed the resident had a skin condition to his right hip, and the type of the skin condition was marked other. The description indicated it was an open area, surrounding skin reddened but blanchable. The wound bed was beefy, red, and scant amount of bright red drainage. The wound was 0.7 centimeters by one centimeter wide and less than 0.1 cm deep. The wound edge was undermining. The stage was identified to be inapplicable. Interview on 12/03/19 at 10:34 A.M. with Director of Nursing (DON) revealed Resident #52's wound was on the on his right hip bone, so the wound should have been identified as a pressure ulcer on the skin condition form. The DON revealed the wound would be classified as a stage two pressure ulcer because it was open. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 12 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to ensure Resident #41 bilateral hand splints were applied per orders. This affect one (Resident #41) of one resident reviewed for range of motion. Findings include: Record review revealed Resident #41 was admitted on [DATE] with diagnoses which included Alzheimer disease, primary generalized osteoarthritis, contracture of left elbow, contracture left hand, and abnormal posture. Minimum Data Assessment (MDS) completed on 10/23/19 revealed Resident #41 is rarely or never understood and has no behaviors. The MDS also revealed Resident #41 required extensive assistance of two staff members for dressing and personal hygiene. Resident #41 also had functional limitations and was impaired on both sides in upper extremities and one side of her lower extremity. Record review for Resident #41's care plan created 10/29/19 included Resident #41 was at risk for impaired functional range of motion (ROM) related to her contracture's and degenerative joint disease (DJD) (a degeneration of joint cartilage and the underlying bone). Interventions in Resident #41's care plan included staff was to apply the left hand splint every day with morning care and remove before supper. Record review revealed Occupational Therapy (OT) had been initiated for Resident #41 on 10/09/19 for hand splinting and discontinued on 11/26/19. OT recommendations for Resident #41 included left and right palm guards with red foam spacers to be worn daily and removed at bedtime. Record review of physician orders for Resident #41 dated 11/27/19 revealed left and right palm guards with red foam spacers were to be worn daily and removed at bedtime. Observation on 12/02/19 at 1:35 P.M. and 12/02/19 3:44 P.M. revealed Resident #41 was laying in bed with her eyes closed. Resident #41 had her hands laying on her chest and palm guards were not present. Observation on 12/03/19 at 11:20 A.M. revealed Resident #41 was sitting up in a wheel chair in the lounge. Resident #41's palm guards were not on her hands. Interview on 12/03/19 at 11:22 A.M. with Licensed Practical Nurse (LPN) #38 confirmed Resident #41 did not have her palm guards on her hands. LPN #38 stated, there are supposed to be red things in her palms, they are not there, I will have to check to see when she is suppose to have them on. Observation on 12/03/19 at 3:45 P.M. revealed Resident #41 was laying in her bed and had no palm protectors on. Interview on 12/03/19 at 3:48 P.M. with STNA #83 confirmed Resident #41 did not have palm protectors on. Observation on 12/04/19 at 9:20 A.M. revealed Resident #41 was sitting up in her chair in the dining room. Resident #41 had no palm protectors on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 13 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 12/04/19 at 9:29 A.M. with Occupational Therapist, registered (OTR) #127 confirmed Resident #41 did not have palm protectors on her hands. The OTR went into Resident #41s room and confirmed the palm protectors were located, (with red inserts), on top of Resident #41's dresser in a clear plastic bin. Interview on 12/04/19 at 9:30 A.M. with OTR #127 revealed Resident #41 had been discharged from OT the previous week and the palm guards with the red inserts were provided at that time. OTR #127 stated, They are in her room and they should be putting them on her, we do intermittent training and I have done training with the staff and showed them how to apply the palm protectors. Record review on 12/04/19 at 9:44 A.M. of OTR #127 documentation confirmed dates of training with staff regarding palm guards for Resident #41 was completed on 11/19/19, 11/21/19 and 11/26/19. The record did not include staff members who had attended. The records reviewed included written information regarding the splinting and positioning program which had also been confirmed to be located on the resident's closet door and in the functional maintenance plan binder located at the nurses station. Record review on 12/04/19 at 2:34 P.M. of Resident #41's treatment records revealed LPN #38 documented for 12/02/19 and 12/03/19 that the left and right palm guards with red foam spacer had been applied upon rising. Interview on 12/04/19 at 3:00 P.M. with Registered Nurse (RN) #9 confirmed Resident #41's treatment records revealed LPN #38 documented for 12/02/19 and 12/03/19 that the left and right palm guards with red foam spacer had been applied upon rising. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 14 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #13 was properly assessed post falling and failed to investigate the falls thoroughly, and failed to ensure Resident #16 and Resident #55 were fed by qualified professionals. This affected one (Resident #13) of two residents reviewed for accidents, and two (Resident #16 and Resident #55) of four residents reviewed for nutrition. Findings include: 1. Record review revealed Resident #13 was admitted on [DATE] with diagnoses including but not limited to Alzheimer's, arthritis, spinal stenosis, muscle weakness, difficulty walking, attention and concentration deficit. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was moderately impaired, she required two person extensive assistance with bed mobility, transfers, and toilet use, and was frequently incontinent of urine. Review of Resident #13's fall history provided by the facility revealed she had a fall on 07/13/19, 07/27/19, and 02/01/19. Review of Resident #13's Interdisciplinary Note dated 07/13/19 at 7:27 A.M. revealed the resident was observed on the floor of her room lying parallel to the bed with her head at the foot of the bed resting on a rolled blanket. Resident #13 stated she hit her head, her range of motion was good, had not bleeding, redness, bruising, and the physician ordered neurological checks. Review of Resident #13's Post Fall investigation completed by the facility related to Resident #13's fall revealed the resident did not have neurological checks completed from 11:00 P.M. on 12/13/19 through 7:00 A.M. on 12/14/19. The investigation did not include when the resident was last checked on our staff statements to help identify the root cause of the resident's fall. Interview on 12/03/19 at 2:02 P.M. with the Director of Nursing (DON) revealed the nurse on shift would have gathered statements from the staff working on 12/13/19 to identify when the resident was last seen or checked on, but there was no evidence of what the staff reported happened during that shift. The DON revealed the interdisciplinary teams review the fall to help identify the root cause. The DON revealed neurological checks are completed for 24 hours if it is suspected a resident hit their head, and confirmed there was no evidence Resident #13 received neurological checks on the above dates. Review of Resident #13's Interdisciplinary Note dated 07/27/19 revealed at 2:06 A.M. the resident was observed laying on the floor by her bed. The resident was confused and delusional. Resident #13 stated her butt was sore, and she had a red area on the back of her right shoulder. Resident #13 denied hitting her head and no injury to her head was noted. Resident #13 was unable to tell what happened. Review of Resident #13's Post Fall investigation related to her fall on 07/27/19 revealed no evidence the facility gathered statements from staff to identify events leading up to her fall or that neurological checks were completed. Interview on 12/04/19 at 1:44 P.M. with DON revealed the facility did not have information of when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 15 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0689 Level of Harm - Minimal harm or potential for actual harm Resident #13 was last checked on when she fell on [DATE]. DON revealed if a fall is unwitnessed and a resident was unable to tell what happened, the facility would use clinical judgement to identify if they hit their head or not. Although Resident #13 was delusional, confused, and could not tell what happened, the DON revealed the facility determined the resident did not hit her head on 07/27/19 based on clinical judgement, and confirmed neurological checks were not completed. Residents Affected - Few Review of the facility policy titled, Emergency Procedures, undated, revealed the facility did not have a procedure to follow if a fall was unwitnessed. If a fall/incident involved head contact, cranial checks would be assessed and documented every shift for 24 hours or as per physician orders, and report any abnormal findings that develop to physician. 2. Review of medical records for Resident #16 revealed an admission date of 10/06/15. The diagnoses for Resident #16 included dementia, dysphagia (difficulty or discomfort in swallowing as a symptom of disease), and abnormal posture. The documentation in Resident #16's care plan dated 06/12/19 included Resident #16 had trouble making appropriate decisions, rarely understands, and was rarely understood. The interventions in the care plan included Resident #16 was to have assistance with eating as needed. The physician orders clarified 12/03/19 for Resident #16's diet was mechanical soft diet with pureed meats. Resident #16's weight record revealed on 05/24/19 Resident #16 weighed 127.2 pounds and on 11/29/19 Resident #16 weighed 133.3 pounds. Observation in the dining room on 12/02/19 at 12:20 P.M. revealed State Tested Nursing Assistant (STNA) #8 had been feeding Resident #16 her lunch. Observation of Resident #16's food card provided with the food tray revealed Resident #16 was to receive a mechanical soft with pureed meats diet. Interview on 12/02/19 at 12:22 P.M. with STNA #8 revealed Resident #16 was unable to feed herself and required assistance for all meals. Observation on 12/02/19 at 5:22 PM revealed Resident #16 and Resident #55 in the dining room being fed by a female not dressed in staff uniform. Interview on 12/02/19 at 5:23 P.M. in the dining room with LPN #38 revealed Resident #16 and Resident #55 had been assisted by Volunteer #201. LPN #38 verified Volunteer #201 routinely volunteered and fed residents who required assistance. Interview on 12/02/19 at 5:30 P.M. with Volunteer #201 confirmed she is a volunteer at the facility and came in every Monday evening and assisted with feeding two to three residents each visit. Volunteer #201 revealed she had no training to feed residents. Interview on 12/02/19 at 6:15 P.M. with the Director of Nursing (DON) revealed volunteers do not receive training for feeding residents. The DON explained, Volunteers are like family, they are not paid assistants, we talked about it a while back and after looking into it, we thought it was ok. Interview on 12/03/19 at 9:00 A.M. with the DON revealed Residents #16 and #55 had no history of any choking episodes. 3. Review of medical record for Resident #55 revealed an admission date of 04/19/13. Medical diagnoses included dementia without behaviors, unspecified lack of coordination, muscle weakness, and a history of cerebral infarct (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain). Physician diet orders for Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 16 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0689 Level of Harm - Minimal harm or potential for actual harm #55 included a regular texture, low concentrated sweets diet, no added salt, and may have small portions at meals as desired. Resident #55's care plan dated 10/31/19 included to assist Resident #55 with eating as needed. Minimum Data assessment dated [DATE] included Resident #55 had no swallowing disorders. Resident #55's weight record revealed on 05/29/19 Resident #55 weighed 186.5 pounds and on 11/27/19 Resident #55 weighed 189.3 pounds. Residents Affected - Few Observation on 12/02/19 at 12:14 P.M. revealed Resident #55 sitting up in her wheelchair in the dining room. Resident #55 required cueing from STNA #29 to take bites of food. Interview on 12/02/19 at 1:00 P.M. with STNA #29 revealed Resident #55 ate 75% of her lunch with cueing and assistance with feeding. Observation on 12/02/19 at 5:30 P.M. revealed Resident #55 ate 75% of supper with assistance of eating from Volunteer #201. Observation on 12/03/19 at 9:27 A.M. revealed Resident #55 ate 100% of her breakfast with assistance by STNA #29 for cueing. Observation on 12/03/19 at 11:49 A.M. revealed Resident #55 sitting up in her wheel chair in the dining room eating her lunch with cueing from STNA #29. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 17 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the width between bed rails were the proper dimensions to ensure safety for 10 residents (Resident #5, Resident #13, Resident #15, Resident #43, Resident #19, Resident #30, Resident #35, Resident #50, Resident #52, Resident #53) out of 69 residents observed for the use of bed rails. Findings include: 1. Record review revealed Resident #52 was admitted on [DATE] with diagnoses including but not limited to dementia, abnormal posture, muscle weakness, history of falling, and attention and concentration deficit. Resident #52's Bed Rails Use Assessment Form, dated 12/02/19, revealed the resident had bed rails due to the resident representative request and for safety. Observation on 12/03/19 at 3:36 P.M. revealed Resident #52 was lying in his bed with bilateral half bed rails up. Observation on 12/03/19 at 4:00 P.M. with Licensed Practical Nurse (LPN) #38, revealed the width between the rails within the bed rail on Resident #52's bed were 7 and 3/4 inches wide. Interview with LPN #38 at this time confirmed this observation. 2. Record review revealed Resident #13 was admitted on [DATE] with diagnoses including but not limited to Alzheimer's disease, muscle weakness, and attention and concentration deficit. Resident #13's Bed Rail Use Assessment Form dated 07/31/19 revealed the resident used bed rails based on the resident/representative request, and for mobility/transferring assistance. Observation on 12/03/19 at 4:04 P.M. with LPN #38 present, revealed the width between the rails within the bed rail on Resident #13's bed were 7 and 3/4 inches wide. Interview with LPN #38 at this time confirmed this observation. 3. Record review revealed Resident #35 was admitted on [DATE] with diagnoses including but not limited to dementia, Alzheimer's disease, and left and right hand contracture. Resident #35's Bed Rail Use Assessment Form, dated 11/29/19, revealed the resident had bed rails due to the resident's request and for safety. Observation on 12/03/19 at 4:10 P.M. with LPN #38 present, revealed the width between the rails within the bed rail on Resident #35 bed were 7 and 3/4 inches wide. Interview with LPN #38 at this time confirmed this observation. 4. Record review revealed Resident #43 was admitted on [DATE] with diagnoses including but not limited to dementia, muscle weakness, history of falling, and lack of coordination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 18 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #43's Bed Rail Use Assessment Form, dated 10/018, revealed the resident used bed rails for the resident/representative request, and for safety and mobility/ transferring assistance. Observation on 12/03/19 at 4:40 P.M. with LPN #103 present, revealed the width between the rails within the bed rail on Resident #43 bed were 7 and 3/4 inches wide. Interview with LPN #103 at this time confirmed this observation. 5. Record review revealed Resident #15 was admitted on [DATE] with diagnoses including but not limited to dementia, anxiety disorder, and muscle weakness. Resident #15's Bed Rail Use Assessment Form dated 11/26/19 revealed the resident's bed rails were recommended due to the resident/resident representative request. Observation on 12/03/19 at 4:40 P.M. with LPN #103 present, revealed the width between the rails within the bed rail on Resident #15 bed were 7 and 3/4 inches wide. Interview with LPN #103 at this time confirmed this observation. 6. Record review revealed Resident #50 was admitted on [DATE] with diagnoses including but not limited to multiple fractured ribs, muscle weakness, difficulty walking, and cognitive communication deficit. Resident #50's Bed Rail Use Assessment Form, dated 11/26/19, revealed the resident had bed rails due to the resident request, and for safety and mobility/transferring assistance. Observation on 12/03/19 at 4:36 P.M. with State Tested Nursing Assistant (STNA) #61 present revealed the width between the rails within the bed rail on Resident #50's bed were 7 and 3/4 inches wide. Interview with STNA #61 at this time confirmed this observation. 7. Record review revealed Resident #5 was admitted on [DATE] with diagnoses including but not limited to muscle weakness, nonrheumatic aortic valve insufficiency, and dependence on wheelchair. Resident #5's Bed Rail Use Assessment Form, dated 11/26/19, revealed the resident had bed rails due to resident/representative request, and safety and mobility/transferring assistance. Observation on 12/03/19 at 4:42 P.M. with State Tested Nursing Assistant (STNA) #61 present revealed the width between the rails within the bed rails on Resident #5's bed were 6 and 1/2 inches wide. Interview with STNA #61 at this time confirmed this observation. 8. Record review revealed Resident #19 was admitted on [DATE] with diagnoses including but not limited to difficulty walking, muscle weakness, cognitive communication deficit, history of falling, and dementia. Resident #19's Bed Rail Use Assessment Form, dated 11/25/19, revealed the resident had bed rails due to resident/representative request, safety, and mobility/transferring assistance. Observation on 12/03/19 at 4:45 P.M. with State Tested Nursing Assistant (STNA) #61 present revealed the width between the rails within the bed rail on Resident #19 bed were 7 and 3/4 inches wide. Interview with STNA #61 at this time confirmed this observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 19 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 0700 Level of Harm - Minimal harm or potential for actual harm 9. Record review revealed Resident #53 was admitted on [DATE] with diagnoses including but not limited to mild cognitive impairment, muscle weakness, and difficulty walking. Resident #53's Bed Rail Use Assessment Form, dated 11/26/19, revealed the resident used bed rails due to the resident/representative request, safety, and mobility/transferring assistance. Residents Affected - Some Observation on 12/03/19 at 4:47 P.M. with State Tested Nursing Assistant (STNA) #61 present revealed the width between the rails within the bed rail on Resident #53's bed were 7 and 3/4 inches wide. Interview with STNA #61 at this time confirmed this observation. 10. Record review revealed Resident #30 was admitted on [DATE] with diagnoses including but not limited to cognitive communication deficit, muscle weakness, difficulty walking, lack of coordination, Parkinson's Disease, and spinal stenosis. Resident #30's Bed Rail Use Assessment Form, dated 11/26/19, revealed the resident had bed rails due to the resident/representative request, safety, and mobility/transferring assistance. Observation on 12/03/19 at 4:48 P.M. with State Tested Nursing Assistant (STNA) #61 present revealed the width between the rails within the bed rail on Resident #30's bed were 7 and 3/4 inches wide. Interview with STNA #61 at this time confirmed this observation. Interview on 12/04/19 at 7:44 A.M. with Director of Nursing (DON) revealed the facility followed Federal Drug Administration (FDA) guidelines regarding bed rail dimensions. DON revealed sometime in October and November, 2019 they completed an audit identifying several resident beds that had bed rails in zone one that were greater than 4 and 3/4 inches wide. DON revealed the facility has been working with volunteers to make covers that go over the bed rails. Review of the facility Bed Inspections audits, dated Fall 2019, revealed ten resident beds had bed rails in zone one that the width between rails was greater than 4 and 3/4 inches. The inspection did not identify which residents resided in the rooms at the time of the inspection. Review of the facility policy titled, Proper Use of Side Rails, revealed if side rails are used, the facility would ensure the correct us of the rails. Guidelines including the facility will assure the correct installation and maintenance of bed rails, prior to use. This includes inspecting and regularly checking the mattress and bed rails for gaps and areas of possible entrapment. Review of the Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued 03/10/06, revealed zone one is any open space within the perimeter of the bed rail. Openings in the rail should be small enough to prevent the head from entering. It is recommended that the space be less than 4 and 3/4 inches, representing head breadth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 20 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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, medical record review, policy review and interview, the facility failed to maintain infection control practices during a pressure ulcer dressing change. This affected one (Resident #5) of three residents reviewed for pressure ulcers. Residents Affected - Few Findings include: Medical record review revealed Resident #5 was admitted on [DATE]. Diagnoses included a facility-acquired Stage III pressure ulcer (full thickness tissue loss with no bone, tendon or muscle exposed) to the right buttock. On 12/04/19 between 10:21 A.M. and 10:45 A.M. observation of Resident #5's pressure ulcer dressing change included the following: Licensed Practical Nurse (LPN) #109 gathered supplies from the treatment cart including a new package of mesalt and a pair of treatment scissors from the top drawer of the treatment cart. The scissors were laying in the drawer and were not in a sealed package. LPN #109 was observed opening the package of mesalt, used the treatment scissors to cut an approximate quarter inch strip of the mesalt, returned the mesalt to the unsealed package and placed the mesalt package back in the cart for future use. LPN #109 did not clean the treatment scissors prior to or after using them to cut the mesalt impregnated gauze. LPN #109 entered the room with the surveyor and the resident was observed laying in bed on her left side and the air mattress was deflated. The plug of the air mattress was observed to be coming out of the electrical socket and the air mattress was not on. This was verified by LPN #109 at the time of the observation and stated the bed was to be on at all times. LPN #109 placed the dressing supplies on the over bed table, washed her hands at the sink, donned gloves, closed the door to the room and positioned the trash can and table next to the bed with her gloved hands. LPN #109 removed the soiled dressing and the soiled dressing was observed to contain moderate wound drainage. LPN #109 then proceeded to cleanse the wound with normal saline, place the quarter inch strip of mesalt in the wound and then removed her gloves and placed them in the trash bag. LPN #109 then went outside the room to get the treatment scissors out of the cart, returned to the room, closed the door, washed her hands, donned gloves and covered the wound with a foam dressing. On 12/04/19 at 10:46 A.M., interview with LPN #109 verified the treatment scissors were not cleaned before use, standard precautions and hand washing/gloving was not completed as indicated during the above observation. Review of the policy: Dressing-Clean Technique dated October 1999 revealed all dressings were to be performed using clean technique unless otherwise specified by physician. Procedures including to remove the soiled dressing and discard into a plastic bag, change gloves, clean wound with sterile normal saline solution or as specified by physician. Review of the undated policy: Standard Precautions revealed staff must use standard precautions when coming in contact with non-intact skin to reduce the risk of transmission of microorganisms from both recognized sources of infection or unrecognized sources of infection in healthcare facilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 21 of 22 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Walnut Hills Nursing Home 4748 Olde Pump Street Walnut Creek, OH 44687 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 Standard precautions included: hand washing before and after gloves are removed and gloves were to be worn when touching contaminated items. 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: 366268 If continuation sheet Page 22 of 22