Inspection·February 6, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm On 02/06/24 at 10:25 A.M. an interview with the DON confirmed the physician was not notified the Zoloft for Resident #31 was not available on 12/09/23, 12/19/23, 12/20/23, and 12/21/23. This deficiency represents non-compliance investigated under Complaint Number OH00149620. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 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, review of the medical record and interview with the staff, the facility failed to ensure fall interventions were in place for Resident #13. This affected one resident ( Resident #13) of six residents reviewed for plan of care. The facility census was 53. Findings included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included heart failure, dementia, hypertension, osteoarthritis, insomnia, history of falling and hearing loss. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident # 13 had severely impaired cognition, was frequently incontinent of bladder and bowel and did not have any pressure areas. Review of the plan of care dated 09/01/22 with a revision date of 01/26/24 revealed Resident #13 was at risk for fall related injuries related to history of falls, impaired cognition, dementia, impaired mobility, impaired hearing, impaired vision, and insomnia. Intervention included a fall mat to the open side of the bed (01/26/24). Observation on 02/05/24 at 2:00 P.M. and 2:30 P.M. revealed Resident #13 was in bed and her floor mat was folded up and leaning against the wall. On 02/05/24 at 2:30 P.M. an interview with State Tested Nursing Assistant #300 confirmed the floor mat for Resident #13 was not on the floor on her open side of the bed but should be on the floor with the resident in bed. Review of the facility policy titled, Accident and Supervision Policy, dated 01/24 revealed the resident's environment would remain as free of accidents and hazards as was possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. This deficiency resulted from an incidental finding during the investigation of Complaint Number OH00149620. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure Resident #31, who had diagnoses of dementia and schizophrenia received adequate treatment, including the administration of the anti-depressant medication, Zoloft as ordered to assist the resident to maintain her highest practicable level of well-being. This affected one resident (#31) of three residents reviewed for medication administration. The facility census was 53. Findings included: Review of the medical record revealed Resident #31 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, dementia, insomnia, schizophrenia, hypertension, hemiplegia, polyneuropathy, restless leg syndrome, neuromuscular dysfunction of the bladder, breast cancer with breast removal, anxiety disorder, Parkinson's disease. Review of the physician's orders revealed Resident #31 had an order for Zoloft 25 milligrams (mg) once daily dated 06/26/23. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #31 had intact cognition. Review of the December 2023 medication administration record revealed Zoloft for Resident #31 was not available on 12/09/23, 12/19/23, 12/20/23 and 12/21/23. Review of the nurse's notes from 12/01/23 to 12/31/23 revealed no documentation of Resident #31 not receiving her Zoloft on 12/09/23, 12/19/23, 12/20/23 and 12/21/23. Review of the Pharmacy reorder from revealed the Zoloft for Resident #31 was not reordered until 12/24/23. On 02/05/24 at 11:45 A.M. an interview with Resident #31 revealed she was never told she did not receive her Zoloft on 12/09/23, 12/19/23, 12/20/23, and 12/21/23. She stated she took her pills in pudding to get them down so she would have never noticed it. On 02/06/24 at 8:20 A.M. an interview with the Director of Nursing (DON) confirmed Resident #31 had not received her Zoloft on 12/09/23, 12/19/23, 12/20/23, and 12/21/23. She stated her Zoloft was not reordered and she did not know why. She stated it was not in their emergency medication kit. This deficiency represents non-compliance investigated under Complaint Number OH00149620. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure the anti-anxiety medication, Ativan was only administered to Resident #13 with a valid physician order. This affected one resident (#13) of three residents reviewed for medication administration. The facility census was 53. Findings Included: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including heart failure, dementia, hypertension, osteoarthritis, insomnia, history of falling and hearing loss. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident # 13 had severely impaired cognition, was frequently incontinent of bladder and bowel and did not have any pressure areas. Review of the medication incident report dated 01/31/24 revealed on 01/10/24 Agency Nurse# 200 gave an Ativan 0.5 milligrams (mg) to Resident #13 without an order. It was not reported until 01/31/24. The notable detail of the report indicated the as needed anxiety medication had a 14-day expiration date and the medication was reordered on 01/11/24. Review of the narcotic count sheet revealed the last dose of Ativan 0. 5 mg Resident #13 had received was on 12/17/23 at 8:00 P.M. Review of the physician's orders revealed Resident #13 had an order for Ativan 0.5 mg every four hours as needed dated 12/11/23. The medication was discontinued on 12/26/23. On 02/05/24 at 12:15 P.M. an interview with the Director of Nursing (DON) revealed the incident with Resident #13 occurred because her Ativan order had been for only 14 days and it was never renewed. She verified Agency Nurse #200 gave an Ativan 0.5 mg to Resident #13 without a physician's order. On 02/05/24 at 3:30 P.M. an interview with Licensed Practical Nurse #100 revealed the pharmacy caught the medication error during an audit on 01/31/24. She did not notify the family until 02/02/24. On 02/06/24 at 9:50 A.M. an interview with Agency Nurse #200 revealed she was not aware she had a medication error on 01/31/24 and she never received a call from the DON with a verbal warning. She stated she had been working midnights that night and she remembered not being able to sign the Ativan off on the Medication Administration Record (MARS). She stated the nurse working before her told her if the resident needed Ativan, it was in the drawer. She stated she gave it to her and when she went to sign it off on the MARS it was not there. She stated she did not think anything of it because they sometimes had issue with not being able to sign off the medications on the MARS. Review of the facility policy titled, Medication Error Policy, dated 04/19 revealed it was the policy of the facility to provide protection from the health, welfare, and rights of each resident by ensuring residents received care and services safely in an environment free of significant medication errors. The facility would ensure medications were administered according to the physician's orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366268 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 366268 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2024 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 0758 This deficiency represents non-compliance investigated under Complaint Number OH00149620. 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 6