Inspection·July 14, 2022

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure communication/notification to Hospice as ordered when Resident #3's blood glucose level was elevated (above 401). This affected one resident (#3) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) and chronic kidney disease, stage 5. Record review revealed the resident received Hospice services. Review of Resident #3's Hospice plan of care, dated 01/03/22 revealed to notify Hospice nurse of changes. The care plan revealed staff would communicate with Hospice to keep up to date on (resident's) condition. A Hospice certification, dated 06/18/22 revealed the resident was ordered Novolog insulin via a sliding scale. The orders indicated if the resident's blood glucose/sugar was 401 or higher to administer eight units of insulin and call Hospice. Review of Resident #3's medication administration record (MAR), dated 06/01/2022 to 07/14/2022 revealed the resident's blood glucose was greater than 401 on 06/29/22 (407), 07/03/22 (404), and 07/08/22 (417). Review of the MAR revealed no evidence Hospice was notified of the elevated blood sugar levels on these dates. In addition, review of Resident #3's corresponding progress notes revealed no evidence Hospice was notified of Resident #3's blood glucose levels greater than 401 on 06/29/22, 07/03/22 and 07/08/22. On 07/13/22 at 8:00 A.M. interview with Registered Nurse (RN) #75 revealed there was no documented evidence Hospice was notified Resident #3's blood glucose levels were greater than 401 on 06/29/22 (407), 07/03/22 (404) and 07/08/22 (417). Review of the facility policy titled Notifying Clinicians, dated 11/18/17 revealed the resident's physician and family member would be notified within 24 hours of occurrence or sooner based on the presence/extent of injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366273 If continuation sheet Page 2 of 5 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 366273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Enclave at Cambridge 8420 Georgetown Road Cambridge, OH 43725 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 Based on record review and interview the facility failed to ensure information contained on Notice of Medicare Provider Non-Coverage forms issued to Resident #15, #19, #26 and #330 was accurate. This affected four residents (#15, #19, #26 and #330) of four residents reviewed for liability/beneficiary notices. Residents Affected - Some Findings include: 1. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #15 was receiving skilled services which were scheduled to end on 02/17/22. The information on the form included the incorrect name and phone number for the Quality Improvement Organization. The form had information for KePro, not the current QIO (Livanta). On 07/12/22 at 12:28 P.M. interview with Social Service Designee #25 verified the Notice of Medicare Provider Non-Coverage form had the incorrect information indicating KePro was the QIO not Livanta for Resident #15. 2. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #19 was receiving skilled services which were scheduled to end on 06/15/22. The information on the form included the incorrect name and phone number for the Quality Improvement Organization. The form had the information for KePro, not the current QIO (Livanta). On 07/12/22 at 12:28 P.M. interview with Social Service Designee #25 verified the Notice of Medicare Provider Non-Coverage form had the incorrect information indicating KePro was the QIO not Livanta for Resident #19. 3. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #26 was receiving skilled services which were scheduled to end on 03/03/22. The information on the form included the incorrect name and phone number for the Quality Improvement Organization. The form had the information for KePro, not the current QIO (Livanta). On 07/12/22 at 12:28 P.M. interview with Social Service Designee #25 verified the Notice of Medicare Provider Non-Coverage form had the incorrect information indicating KePro was the QIO not Livanta for Resident #26. 4. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #330 was receiving skilled services which were scheduled to end on 03/11/22. The information on the form included the incorrect name and phone number for the Quality Improvement Organization. The form had the information for KePro not the current QIO (Livanta). On 07/12/22 at 12:28 P.M. interview with Social Service Designee #330 verified the Notice of Medicare Provider Non-Coverage form had the incorrect information indicating KePro was the QIO not Livanta for Resident #330. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366273 If continuation sheet Page 3 of 5 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 366273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Enclave at Cambridge 8420 Georgetown Road Cambridge, OH 43725 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 record review and interview the facility failed to ensure the justified use of a psychoactive medication for Resident #3. This affected one resident (#3) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and Alzheimer's disease. Review of a pharmacy recommendation, dated 01/03/22 revealed Resident #3 was receiving the anti-psychotic medication, Quetiapine (Seroquel) for agitation but lacked an allowable diagnosis to support its' use. The recommendation included a list of appropriate diagnoses/conditions listed including refractory major depression. The recommendation noted the facility nurse practitioner chose a diagnosis of refractory major depression on the form. However, there was no evidence of refractory major depression (treatment-resistant depression that doesn't respond to an adequate course of least two antidepressants) listed as a diagnosis for the resident in the electronic medical record under the residents' diagnoses tab. Review of Resident #3's anti-psychotic medication plan of care, dated 02/19/22 revealed to assess daily for behaviors manifested and notify the physician if medication could be reduced to the lowest possible therapeutic dose. There was no evidence of the diagnosis for use of the medication. Review of Resident #3's behavior monitoring documentation, dated 05/2022, 06/2022, and 07/2022 revealed the resident's monitored behavior was agitation. The facility documented the resident had seven days of agitation behavior during the three month time span. Record review revealed the resident received Hospice services. A Hospice certification, dated 06/18/22 revealed no evidence the resident had a diagnosis of refractory major depression or diagnosis for the use of Quetiapine. The documentation revealed the resident received Quetiapine (Seroquel) 25 milligrams (mg) twice daily for agitation. Review of Resident #3's physician orders and Medication Administration Record (MAR) for 07/2022 revealed the resident was ordered Quetiapine (Seroquel) 25 mg twice daily for refractory major depression and Sertraline (Zoloft) 50 mg once a day for depression. On 07/13/22 at 8:00 A.M. interview with Registered Nurse (RN) #75 revealed the facility was not able to find supporting evidence Resident #3 had a diagnosis of refractory major depression. The facility reported the nurse practitioner had just chosen that diagnosis from the pharmacy recommendation in January 2022, as agitation was not an appropriate diagnosis for the use of Quetiapine. The RN confirmed the diagnoses was not listed on the resident's diagnoses list or on the Hospice diagnoses list. The facility was unable to provide justified evidence for the use of Quetiapine for Resident #3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366273 If continuation sheet Page 4 of 5 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 366273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/14/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Enclave at Cambridge 8420 Georgetown Road Cambridge, OH 43725 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure meals were prepared and served as per the planned menu. This affected all 26 residents residing in the facility. Findings include: Review of the meal spreadsheet, dated Spring/Summer 2022 revealed the dinner menu for Monday included pureed soft, cooked vegetables for resident's receiving pureed diets, soft, cooked vegetables for the resident's receiving mechanical soft diets, and lettuce and tomato salad for the resident's receiving regular diets. The spreadsheet revealed the alternative main dish was creamy chicken spaghetti. Review of the meal tickets, dated 07/11/22 revealed no evidence of a pureed or mechanical soft vegetable or lettuce and tomato salad for regular diets, or the alternative main dish of creamy chicken spaghetti. On 07/11/22 at 4:31 P.M. observation of dinner meal revealed no evidence of a pureed or soft vegetable, lettuce and tomato salad, or creamy chicken spaghetti was prepared and available. At the time of the observation, interview with Dietary Manger (DM) #24 revealed the vegetable and lettuce and tomato salad was too much food to go along with the enchilada and red bean rice being served. DM #24 revealed neither the vegetable or the lettuce and tomato salad were prepared for the meal. DM #24 revealed no creamy chicken spaghetti was prepared as there were no pre-orders for it. When asked if DM #24 talked with the dietician regarding the changes, the DM reported he tried to call her, but she was on vacation. During the interview, DM #24 also verified in review of the meal tickets, the choice of vegetable, lettuce and tomato salad, or creamy chicken spaghetti were not included as selections for the meal. The facility identified all 26 residents received a meal tray from the kitchen. Review of resident council and food committee minutes, dated 06/29/21 to 06/28/22 revealed residents voiced they would like more (food) choices. Review of facility policy titled Food and Nutrition Service, dated 10/2017 revealed each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366273 If continuation sheet Page 5 of 5