Health inspection·August 10, 2021

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** Based on observation, interview and record review, the facility failed to prevent the development of an avoidable stage II pressure ulcer. This affected one (Resident #23) of two residents identified with pressure ulcers. Thee facility census was 44. Residents Affected - Few Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses included vascular dementia with behavioral disturbance, hypothyroidism, pseudobulbar affect, schizoaffective disorder, chronic pain syndrome, hemiplegia affecting right dominant side, muscle wasting and atrophy, stiffness of unspecified joint, cognitive communication deficit, psychotic disorders with delusions, restlessness and agitation, alcohol abuse, seizures, morbid obesity, impulse disorder, and unspecified abnormal involuntary movements. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 01/02/21, revealed this resident triggered for the care area pressure ulcer and the need for a new, revised, or continued care plan to address to address the care area. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/21 revealed the resident had severely impaired cognition. The resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, toileting, dressing, and personal hygiene and was assessed to require extensive assistance from one staff member for eating. This resident was assessed to be at risk for pressure ulcer development and to not have any current pressure ulcers. Review of the nursing progress note, dated 07/28/21 at 10:49 A.M., revealed an open area to the resident's left ankle measured 1.7 centimeters (cm) long by 0.4 cm wide. Review of the nursing progress note dated 07/28/21 and timed 12:45 P.M., revealed the State Tested Nursing Assistant (STNA) reported to the nurse Resident #23 had blood on her sheets and was not sure where it was coming from. The nurse found the resident's left ankle had blood coming from it due to an open area from friction. The resident was rubbing her feet back and forth on the sheets. Review of the physician order, dated 07/28/21, revealed an order to cleanse the area to left ankle with normal saline, pat dry, apply triple antibiotic ointment, cover with mepilex, and change every day and as needed until healed. Review of the physician order, dated 07/29/21, revealed an order for a moon boot to be on the left foot at all times when in bed. Review of the care plan, dated 08/01/21, revealed this resident was at increased risk for pressure ulcer development related to disease process, decreased mobility, and moisture exposure. Interventions included to follow facility policies for the prevention and treatment of skin breakdown, monitor nutritional status, and provide assistance to turn and reposition every two hours and more often as needed. Observation on 08/02/21 at 11:25 A.M. revealed Resident #23 had a round, reddened area to her left outer ankle which was slow to blanch and contained a small open area to the center. The area did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 2 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 have a treatment or dressing in place. This was determined to be a stage II ulcer. Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Practical Nurse (LPN) #48 on 08/02/21 at 11:25 A.M. verified Resident #23 had an open area located on the bony prominence of her left outer ankle and the surrounding skin was red, slow to blanch, and was round. Residents Affected - Few Observation on 08/03/21 at 2:06 P.M. revealed the wound to the left outer ankle of Resident #23 did not have a treatment in place as ordered by the physician. Interview with LPN #46 on 08/03/21 at 2:06 P.M. verified there was not a dressing or treatment in place to the wound on the left outer ankle of Resident #23. Observation on 08/04/21 at 8:15 A.M. revealed Resident #23 was lying in bed on her left side with her left ankle lying directly against the mattress. There was not a treatment or dressing in place to the wound on the left outer ankle of Resident #23 and the resident did not have a moon boot on her left foot as ordered by the physician. The moon boot was observed lying on the dresser across the room from the bed of Resident #23. Resident #23 was observed moving her left foot and left outer ankle back and forth across the mattress. Interview with STNA #11 on 07/04/21 at 8:15 A.M. verified Resident #23 did not have a treatment or dressing in place to the wound on her left ankle and did not have the moon boot on her left foot. STNA #11 verified the moon boot was laying on the dresser across the room and stated she had not removed it from the resident since she started her shift at 7:00 A.M. Observation on 08/04/21 at 11:00 A.M. revealed Resident #23 was in her wheelchair in the lobby and did not have a treatment or dressing in place to the wound on her left outer ankle. Interview with Registered Nurse (RN) #42 on 08/04/21 at 11:00 A.M. verified the wound to the left outer ankle of Resident #23 did not have a treatment or dressing in place as ordered by the physician. RN #42 verified there was an open area located on the bony prominence of the left outer ankle of Resident #23 which was surrounded by a red, circle shaped area of skin. Interview with Clinical Regional Director (CRD) #62 on 08/05/21 at 10:00 A.M. verified the facility had not completed a pressure ulcer prevention or skin alteration prevention care plan with interventions prior to the one dated 08/01/21. Review of the facility policy titled Prevention of Pressure Ulcers/Injuries, revised July 2017, revealed the facility was to review the residents' care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Review of the National Pressure Injury Advisory Panel (NPIAP) pressure ulcer guidance titled NPIAP Pressure Injury Stages (https://npiap.com/page/PressureInjuryStages) revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 3 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. 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: 366296 If continuation sheet Page 4 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, medical record review, and facility policy review, the facility failed to timely monitor and address a resident's weight loss and ensure the residents received nutritional interventions recommended by the Dietary Technician and/or Physician. This affected two (Resident #09 and #11) of five residents reviewed for nutrition. The facility census was 44. Residents Affected - Few Findings include: 1. Record review for Resident #09 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar disorder, essential hypertension, dementia with behavioral disturbance, hypertension, chronic obstructive pulmonary disease, and fusion of spine. Review of the physician order dated 06/14/21 revealed Resident #09 was ordered daily weights and was on Lasix (diuretic) 20 milligrams (mg) from 06/14/21 to 07/20/21. Review of Resident #09's admission Minimum Data Set (MDS) assessment, dated 06/21/21, revealed the resident was moderately cognitively impaired and required supervision with eating. Review of Resident #09's nutritional risk assessment, dated 06/21/21, revealed the resident would begin the boost glucose control (high calorie nutritional supplement) twice a day for additional nutritional support. Review of the progress note from Dietary Technician #60, dated 06/22/21, revealed Resident #09 was admitted [DATE]. Resident #09 was on a low concentrated sweets diet with thin liquids. Resident #09 had no chewing or swallowing problems. Resident #09 was alert and verbal with preferences and could feed himself. Resident #09 had a poor to fair appetite. The resident was recommended to have a liquid protein 30 milliliters (ml) every day and a stress tablet or zinc in place. Resident #09 would begin boost glucose control three times daily for additional nutrition support. The facility would continue to monitor nutrition related issues and would make recommendations as needed. Review of the physician orders from 06/22/21 to 08/01/21 revealed no boost supplement was ordered for Resident #09. Review of Resident #09's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 06/22/21 to 08/01/21 revealed no boost supplement was given to Resident #09. Review of the nutritional care plan, dated 06/25/21, revealed Resident #09 had a nutritional problem or potential nutritional problem. Interventions included to administer medications as ordered, explain and reinforce to the resident the importance of maintaining the diet ordered, honor dietary preferences as necessary, monitor weight, skin, laboratory results, diet tolerance, hydration status, and provide and serve supplements as ordered. Review of Resident #09's weights revealed the resident weighed the following: weighed 179.6 pounds (lbs) on 06/15/21, 178 lbs on 07/15/21, 161.8 lbs on 07/21/21, 158 lbs on 07/24/21, 158 lbs on 07/25/21, 158 lbs on 07/27/21, 158 lbs on 07/28/21, 155.4 lbs on 07/29/21, 155.7 lbs on 07/30/21, 156.2 lbs on 07/31/21, 156.4 lbs on 08/01/21 and 156.2 lbs on 08/02/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 5 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note from Dietary Technician #60, dated 08/02/21, revealed Resident #09 weighed 156.4 lbs. showing a 23.2-pound weight loss representing a 12.9 percent weight loss since admission. Resident #09 continued with diuretic therapy in place and was now on daily weights. Resident #09's appetite varied from 25 to 100 percent and Resident #09 had refused a few meals. Resident #09 did snack between meals and in the evenings. Resident #09 would begin boost glucose control with meals for additional nutritional support. Weight loss was probable due to dietary restrictions and fluid loss with diuretics. The facility would continue to monitor nutrition related issues and would make recommendations as needed. Telephone interview with Dietitian #61 on 08/03/21 at 2:18 P.M. verified Resident #09 did not receive his boost supplement that was recommended on 06/22/21 and she was not sure why the resident did not receive the supplement. Dietitian #61 stated she started to recently become involved in the resident's weight loss and she had contacted the facility about his diuretic use, but she had not received a reply back. Dietitian #61 stated she goes to the facility monthly and supervises the dietary technician. Telephone interview on 08/03/21 at 3:59 P.M. with Dietary Technician #60 revealed Resident #09 was placed on a low concentrated sweets diet upon admission and his diet was restricted. Dietary Technician #60 stated that she recommended boost three times a day on 06/22/21 but the boost was never put in place or given to Resident #09. Dietary Technician #60 reported she even went into the kitchen and told the staff about the supplement. Dietary Technician #60 also made sure the supplement was available in the kitchen. Dietary Technician #60 reported nursing staff puts in orders for supplements based on the recommendations. Dietary Technician #60 stated Resident #09 was on Lasix since admission and that could have impacted his weight. Dietary Technician #60 verified Resident #09 did not receive the daily weights that were ordered from 06/14/21 until 07/24/21. Interview with Regional Clinical Director #62 on 08/04/21 at 1:30 P.M. revealed the facility did not have any additional information on Resident #09's boost supplement or weight loss. 2. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus with unspecified complications, hyperlipidemia, extrapyramidal and movement disorder, hypothyroidism, schizoaffective disorder, pneumonia, dysphagia, and muscle weakness. Review of Resident #11's quarterly MDS assessment, dated 07/25/21, revealed the resident was moderately cognitively impaired and required limited assistance with eating. Review of the weights from 06/18/21 to 07/30/21 revealed Resident #11 weighed 176.4 pounds lbs on 06/18/21, 160.2 lbs on 07/17/21 and 169.8 lbs on 07/30/21. Review of Resident #11's care plan, dated 06/25/21, revealed the facility would provide and serve supplements as ordered. Review of the physician's order, dated 07/09/21, revealed Resident #11 was to receive a magic cup (high calorie frozen nutritional supplement) two times a day. Review of Resident #11's lunch meal ticket, dated 08/03/21, revealed the resident was to have two magic cups at meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 6 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 0692 Level of Harm - Minimal harm or potential for actual harm Observation of tray line on 08/03/21 at 11:50 A.M. revealed [NAME] #29 to provide Resident #11 with a mechanical soft tray that included peach crisp, mechanical pork, a roll with butter, potatoes and cauliflower. No magic cup was served or placed on the resident's tray. Further observation revealed Resident #11's meal tray was taken out of the kitchen and served to Resident #11 in the dining room without a magic cup supplement on the tray. Residents Affected - Few Interview with [NAME] #29 on 08/03/21 at 11:50 A.M. verified Resident #11 was not served a magic cup on the tray. [NAME] #29 also verified the magic cups were to be served on the resident meal trays. [NAME] #29 verified the kitchen had magic cups in their freezer, but failed to serve them on Resident #11's meal tray. Review of the facility's weight assessment and intervention policy, dated September 2008, revealed the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss. Review of the facility's nutrition and unplanned weight loss policy, dated September 2012, revealed nursing staff would monitor and document resident weights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 7 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 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 observations, interviews, and record review, the facility failed to follow appropriate infection control to prevent the spread of COVID-19. This had the potential to affect the 44 residents residing in the facility. The facility census was 44. Residents Affected - Many Findings include: Record review for Resident #295 revealed this resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, insomnia, and schizoaffective disorder. This resident was transferred to the hospital on [DATE] for an inpatient psychiatric stay and returned to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/06/21, revealed this resident had moderately impaired cognition and was assessed to require supervision for bed mobility, transfers and toileting. Review of the immunization history for Resident #295 revealed he had refused the COVID-19 vaccination. Review of the nurses progress note, dated 07/30/21, revealed this resident had been placed in quarantine/isolation with an obtained order by the physician due to potential exposure to the virus. Observation on 08/02/21 at 12:21 P.M. revealed a sign was posted on the door of Resident #295's room which contained Droplet/Contact Precautions. State Tested Nursing Assistant (STNA) #13 entered the room of Resident #295 to deliver his lunch meal tray wearing a surgical mask. STNA #13 did not don gloves, a gown, a face shield, or an N-95 face mask prior to entering the room. STNA #13 then proceed to begin delivering lunch meal trays to additional resident rooms. Interview with STNA #13 on 08/02/21 at 12:26 P.M. verified staff did not don any Personal Protective Equipment (PPE) other than a surgical mask when entering the room of Resident #295 despite the resident being in droplet/contact precautions. Observation on 08/04/21 at 8:35 A.M. revealed STNA #11 entered the room of Resident #295 wearing a surgical mask and face shield to deliver his breakfast meal tray. STNA #11 exited the room, performed hand hygiene and did not clean her face shield, then proceeded to deliver breakfast meal trays to other residents in the facility. Interview with STNA #11 on 08/04/21 at 8:40 A.M. revealed staff only wore a surgical mask and face shield when entering the room of Resident #295. STNA #11 stated facility management notified staff of additional PPE required to enter resident rooms and had not told staff to wear any additional PPE into the room of Resident #295. Observation on 08/04/21 at 8:50 A.M. revealed STNA #13 entered the room of Resident #23 to deliver juice while wearing a face shield and surgical mask and no additional PPE. STNA #13 then exited the room, did not clean her face shield, then continued delivering juice to additional residents. Interview with Registered Nurse (RN) #42 on 08/04/21 at 8:50 A.M. verified STNA #13 had just exited (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 8 of 9 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 366296 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedars of Lebanon Care Center 102 East Silver Street Lebanon, OH 45036 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the room of Resident #23 wearing a face shield and surgical mask and no additional PPE. RN #42 verified Resident #295 was currently in droplet and contact precautions for COVID-19 and staff were to don an N-95 respirator mask, gown, gloves, and face shield prior to entering the room and should clean their face shields after exiting the room. Review of the facility policy titled COVID-19, dated 04/27/21, revealed quarantine would be recommended for residents who had not received the COVID-19 vaccine who left the facility for longer than 24 hours. Review of the CDC recommendations for PPE usage in healthcare personnel (HCP) providing care for residents in quarantine titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), revised on 03/29/21, revealed HCP should wear an N-95 or higher-level respirator mask, eye protection, gloves, and gown when caring for residents with suspected or unknown COVID-19 status. This deficiency substantiates Complaint Number OH00111708. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366296 If continuation sheet Page 9 of 9