Inspection·September 23, 2022

F 0607 not checked against the NAR. No reference checks were available for review. Level of Harm - Minimal harm or potential for actual harm Interview on 09/22/22 at 11:45 A.M. with HR #106 verified the above background and NAR checks were not completed on or before an employee's date of hire to ensure no employee had findings concerning abuse, neglect, exploitation or misappropriation of residents' property. HR #106 also verified the lack of reference checks identified during the personnel file review. Residents Affected - Some Interview on 09/22/22 at 1:56 P.M. with the Director of Nursing (DON) and the Administrator revealed they were unaware all staff, not just nurses and STNAs, had to be checked against the NAR prior to an employee's date of hire to ensure no findings of abuse or neglect. Review of the facility's policy, Abuse, Neglect and Exploitation, revised 02/19/21 revealed potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants. Screenings may be conducted by the facility itself, third party agency or academic institution. The facility will maintain documentation of proof the screening occurred. The policy did not specifically address a timeframe for the background and reference checks to be conducted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 2 of 8 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 09/23/2022 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. Based on observation, interview, record review and policy review the facility failed to ensure a resident received recommended Restorative Range of Motion (ROM) services after being discharged from therapy. This affected one of one resident reviewed for restorative nursing services (Resident #27). The facility census was 44. Findings included: Review of Resident #27's medical record revealed an admission date of 02/10/06. Diagnoses included spastic quadriplegic cerebral palsy, pain in her left hand, and dependence of a wheelchair. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/09/22, revealed the resident was cognitively intact. The assessment identified that Resident #27 used a wheelchair and required extensive physical assistant with the help of two people for bed mobility/transferring and extensive physical assistance with physical help of one person for personal hygiene. Review of Resident #27's Care Plan, dated 12/01/21, revealed the resident had an activity of daily living self-care deficit related to weakness, impaired mobility, spastic movements due to cerebral palsy, poor trunk control, and pain. The resident also had a care plan for a splint or brace to her left wrist due to decreased range of motion. Interventions included passive ROM to splinted extremity and to remind the resident of the importance of wearing the splint and the potential for decreased ROM if she refuses. Observation and interview on 09/19/22 at 11:11 A.M. revealed Resident #27 to have contractures to her bilateral hands and was dependent on a wheelchair. Upon interview, Resident #27 stated that she is not receiving any type of therapy services including restorative and staff do not provide ROM exercises to her bilateral hands. Review of Resident #27's 03/13/20 Occupational Therapy (OT) discharge paperwork from the last time she received therapy services revealed she was to have a restorative program upon discharge. The program was established and staff trained and was for Active ROM including two sets of 10 for all joints. Interview on 09/20/22 at 11:52 A.M. State Tested Nursing Assistant (STNA) #103 revealed she does not perform ROM for Resident #27 and did not know she was to receive ROM services. Interview on 09/20/22 at 11:55 A.M. STNA #104 revealed she does not perform ROM for Resident #27 and never has. She stated that they were not able to complete ROM on residents when they were understaffed, but now that it has improved, they are going to start the program again. Interview on 09/20/22 at 11:56 A.M. [NAME] Clerk #105 revealed that she is now responsible for completing restorative programs on the residents in the facility. She confirmed that Resident #27 is not receiving a restorative program and does not receive ROM exercises. Interview on 09/20/22 at 2:11 P.M. the Director of Nursing confirmed the facility did not initiate a restorative program and they are not completing ROM exercises as indicated on Resident #27's care plan and OT recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 3 of 8 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 09/23/2022 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 Review of the undated facility policy, Restorative Nursing Program, revealed restorative nursing programs will be provided for any resident who has been identified as having a need for such service. These services will include consistent and structured programs designated by the licensed nurse and can be provided by the STNAs or trained restorative aides on a day to day basis. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 4 of 8 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 09/23/2022 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a resident received adequate monitoring while receiving blood thinning medication. This affected one of six residents reviewed for unnecessary medication use (Resident #11). The facility census was 44. Residents Affected - Few Findings include: Review of Resident #11's medical record revealed an admission date of 01/07/22. Diagnoses included unspecified dementia without behavioral disturbance, anemia, atherosclerosis heart disease of native coronary, edema, depression, and pain. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/22, revealed the resident had a cognitive impairment. The assessment identified that Resident #11 required extensive physical assistant with the help of two people for bed mobility and transferring. Review of Resident #11's Care Plan, dated 06/24/22, revealed the resident has impaired cerebrovascular status related to hypertension and coronary artery disease. Interventions included aspirin and Plavix (blood thinning medications) therapy as ordered and to monitor for signs and symptoms of a bleeding disorder, and abnormal bruising. Review of Resident #11's September 2022 physician orders revealed orders to monitor for signs and symptoms of bleeding, bruising, light headiness, and paleness every shift, and geri-sleeves to bilateral arms every shift for skin protection. Additionally the resident was also noted to be on two anticoagulant (blood thinning) medications, Aspirin 81 milligrams (mg) daily and Plavix 75 mg daily. Observation on 09/19/22 at 10:45 A.M. revealed Resident #11 sitting in her bed. She had short sleeves on with Geri-sleeves underneath her shirt. She had a large black and purple bruise to left arm by elbow. Review of Resident #11 skin assessments and nursing notes revealed no evidence of documentation related to the large bruise on the resident's left arm. Interview on 09/21/22 at 9:06 A.M. Resident #11 stated that she obtained the bruise a few days ago. Interview on 09/21/22 at 5:18 P.M. Licensed Practical Nurse (LPN) #100 who worked 09/19/22 revealed she did not assess Resident #11 for bruising as the resident's order indicated to do. Interview on 09/22/22 at 10:33 A.M. with LPN #102 who worked 09/20/22 revealed she also did not assess Resident #11 for bruising as the resident's order indicated to do. Review of Resident #11's skin assessment, dated 09/21/22, (after the surveyor reported the bruise to the facility staff) revealed the resident had a greenish yellow with purple proximal edge discoloration noted with a length of 8 centimeters (cm) and a width of 11 cm. Interview on 09/22/22 at 10:11 A.M. the Director of Nursing (DON) confirmed the facility has not been monitoring Resident #11 for bruising as ordered for the use of her blood thinning medications. She continued that if the facility nurses were monitoring the resident as ordered Resident #11's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 5 of 8 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 09/23/2022 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 0757 bruise would have been identified timely. The DON continued that an investigation would be initiated into how the resident obtained the large bruise. 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 6 of 8 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 09/23/2022 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and policy review, the facility failed to ensure residents receiving antibiotic medication had appropriate indication for antibiotic use. This affected two (Resident #25 and #29) of five residents reviewed for medication use. The facility census was 44. Residents Affected - Few Findings include: 1. Review of Resident #25's medical record revealed an admission date of 04/28/20 with diagnoses that included cerebrovascular accident with hemiplegia and congestive heart failure. Further review of the medical record revealed antibiotic orders on 10/01/21 through 10/08/21 for the use of amoxicillin (antibiotic) 500 milligrams (mg) three times daily. Review of the facility Revised McGreer Criteria for Infection Surveillance Checklist (antibiotic assessment form) completed on 10/04/21 indicated the amoxicillin was initiated due to Resident #25 with a complaint of ear fullness. Further review of the antibiotic assessment form revealed no evidence of any other symptoms reported by the resident. The form indicated the use of antibiotics did not meet criteria for antibiotic use. Interview with Registered Nurse (RN) #101 on 09/22/22 at 10:45 A.M. verified there was no evidence of appropriate indication of use for the amoxicillin for ear fullness due to not meeting McGreer criteria for antibiotic use. 2. Review of Resident #29's medical record revealed an admission date of 11/18/21 with diagnoses that included diabetes mellitus type II and schizoaffective disorder. Further review of the medical record revealed antibiotic orders on 01/21/22 through 02/03/22 for Levaquin (antibiotic) 500 mg every day for a urinary tract infection (UTI), 03/09/22 through 03/12/22 for Cipro (antibiotic) 500 mg every 12 hours for suspected UTI, 03/12/22 for Ceftriaxone (antibiotic) 1 gram (gm) intramuscularly (IM) times one only for suspected UTI, 03/12/22 through 03/16/22 for Levaquin 750 mg every day for UTI, 05/18/22 through 05/27/22 Augmentin 875-125 mg every 12 hours for a perforated ear drum and 07/27/22 through 08/02/22 for UTI. Review of the antibiotic assessment form with a review date of 01/20/22 revealed criteria not met for antibiotic use for a UTI. Review of the antibiotic assessment form with a review date of 03/10/22 revealed a urinalysis and culture was completed on 03/08/22 with results reported on 03/10/22. Review of the lab culture revealed Streptocococcus Viridans (gram-positive bacteria) growth. No sensitivity was completed to determine which antibiotic was appropriate for use. Review of the antibiotic assessment form with a review date of 05/19/22 revealed preventative antibiotic use for a perforated ear drum for Resident #29. Further review of the assessment form revealed on 05/18/22 Resident #29 had no complications or symptoms from the perforated ear drum. Review of the antibiotic assessment form with a date of 07/26/22 revealed antibiotic use for a UTI. Further review of the antibiotic assessment form revealed Resident #29 did not meet criteria for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 7 of 8 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 09/23/2022 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 0881 use of an antibiotic. Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse (RN) #101 on 09/22/22 at 10:45 A.M. verified Resident #29 did not meet McGreer criteria for appropriate antibiotic use on 01/21/22, 05/18/22 and 07/27/22. RN #101 also verified that Resident #29 received three different antibiotics for one UTI on 03/09/22 with no culture sensitivity completed to determine appropriate antibiotic use. Residents Affected - Few Review of the facility policy, Antibiotic Stewardship, with a revision date of 10/2019 revealed: Purpose - it is the policy of this facility to ensure antibiotics are ordered and administered appropriately in order to reduce likelihood of antibiotic resistance. Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Policy Implementation - If an antibiotic is indicated, per determination by McGreer's criteria, prescribers will provide complete antibiotic order including the following elements: drug name, dose, frequency of administration, duration of treatment, route of administration and indication for use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 If continuation sheet Page 8 of 8