Health inspection·August 23, 2023

F 0686 administered. Level of Harm - Minimal harm or potential for actual harm Review of the wound assessment for Resident #08 dated 08/14/23, revealed the resident had an unstageable pressure ulcer to the upper sacrum which measured 1.5 centimeters (cm) in length by 2.5 cm in width by 0.1 cm in depth with 50 percent (%) slough tissue noted to the wound bed. Resident #08 was admitted to the facility under hospice care and was at high risk for the development of pressure ulcers. Residents Affected - Few Interview with DON on 08/23/23 at 9:01 A.M., confirmed Resident #08 was admitted on [DATE] and was receiving hospice services due to malignant neoplasm of the colon. The DON confirmed facility did not complete a skin assessment upon admission for the resident, the facility did not conduct a risk assessment for the potential for the development of pressure ulcers, and the facility did not initiate a baseline care plan regarding prevention of pressure ulcers for resident. The DON confirmed the facility did not put a care plan in place for resident's risk of skin breakdown until 08/16/23 which was after the resident had already developed a pressure ulcer which was first noted by staff on 08/11/23 and first staged by the wound nurse practitioner on 08/14/23. Review of the undated facility policy titled Pressure Ulcers Skin Breakdown Clinical Protocol revealed the nursing staff will assess and document an individual's significant risk factors for developing pressure sores and staff will examine the skin of a new admission for ulcerations or alterations in skin. Review of the undated facility policy titled Pressure Reducing and Relieving Devices revealed residents at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static air, alternating air, or air loss gel when lying in bed. The Braden scale is used to help determine the risk for developing pressure ulcers. Mattresses are chosen for the resident based on Braden Scale pressure ulcer risk. Review of the online resource NPUAP resource titled Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline at (https://npiap.com/general/custom.asp?page=2014Guidelines) downloaded on 08/23/23 revealed on page 48 that the facility should use a structured approach to risk assessment that is refined through the use of clinical judgment and informed by knowledge of relevant risk factors to assess residents' risk for the development of skin breakdown. For individuals at risk of pressure ulcers, the facility should conduct a comprehensive skin assessment as soon as possible but within eight hours of admission. This deficiency represents non-compliance investigated under Complaint Number OH00145623. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366316 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 366316 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220 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 record review, observation, resident interview, staff interview, review of facility incident log, and review of the facility policy, the facility failed to investigate resident falls and implement interventions to prevent recurrence. This affected one resident (#38) of three residents reviewed for falls. The facility census was 50 residents. Findings include: Review of the medical record for Resident #38 revealed an admission date of 08/17/23 with diagnoses including hypertension, chronic kidney disease, and major depressive disorder. Review of the care plan dated 08/18/23 for Resident #38, revealed the resident was at risk for falls related to gait/balance problems. Interventions included the following: ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, monitor for attempts to self-rise and periods of restlessness, non-skid socks to bed worn in bed, therapy evaluate and treat as ordered or as needed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review of the nurse's progress note dated 08/21/23 timed at 12:54 A.M. for Resident #38, revealed the resident had a fall and complained of head pain and leg pain and was administered Tylenol (over the counter pain relief) with effectiveness. The notes did not include a description of how the fall occurred or any new interventions implemented to prevent reoccurrence. Review of neurological (neuro) flow sheet dated 08/21/23 for Resident #38, revealed neuro checks following the fall were within normal limits. Review of the facility's incident log revealed it did not include Resident #38's fall on 08/21/23. Observation of Resident #38 on 08/22/23 at 3:25 P.M., revealed the resident had bruising to her left-hand ring finger. Interview with Resident #38 on 08/22/23 at 3:25 P.M., confirmed she fell on [DATE] during the night when she tried to transfer herself from bed to chair. Resident #38 confirmed she hit her head and bruised her left-hand ring finger during the fall. Interview on 08/23/23 at 9:01 A.M. with the Director of Nursing (DON), confirmed the facility administration was not aware of Resident #38's fall on 08/21/23 and had not conducted a fall investigation. The DON confirmed Resident #38's record did not include a description of how the fall occurred. Review of the undated facility policy titled Falls, revealed staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366316 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 366316 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220 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 This deficiency represents non-compliance investigated under Complaint Number OH00143101. 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: 366316 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 366316 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on record review, observation, resident interview, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #46's pain was managed during a dressing change to the residents Stage IV pressure ulcer (full-thickens loss of skin and tissue loss with exposed or directly palpable fascia, muscle tendon ligament, cartilage, or bone in the ulcer) on her sacrum. This resulted in Actual Harm to Resident #46 when the resident was not pre-medicated for pain prior to the wound care treatment which resulted in the resident exhibiting signs of severe pain and the nurse continued the wound treatment without addressing the resident's pain. This affected one resident (#46) of the three residents reviewed for pain management. The facility census was 50. Residents Affected - Few Findings include: Review of the record for Resident #46 revealed an admission date of 10/08/21 with diagnoses of multiple sclerosis (MS), diabetes mellitus (DM), dementia without behavioral disturbance, mood disorder, chronic viral hepatitis B, and personality disorder. Review of the physician orders dated 10/08/21 for Resident #46, revealed the resident was ordered to receive Tylenol 500 milligram (mgs) every six hours as needed (PRN) for pain and Percocet (narcotic pain relief) 5-325 mg PRN every six hours for moderate to severe pain. Review of the significant change Minimum Data Set (MDS) assessment 3.0 for Resident #46 dated 08/13/23, revealed the resident was cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Review of the wound Nurse Practitioner (NP) note for Resident #46 dated 08/21/23, revealed the resident had a large stage IV pressure ulcer over her sacrum which was unavoidable due to severe hypoalbuminemia which measured 6.5 centimeters (cm) in length by 1.0 cm by 3.0 cm, undermining with maximum distance of 2.0 cm. Osteomyelitis was suspected and the resident was being treated with Doxycycline (antibiotic). Review of the controlled substance sheets for Resident #46, revealed the last dose of PRN Percocet 5-325 mg administered to the resident, prior to wound care was recorded as being administered on 08/22/23 at 9:30 A.M. Review of the care plan for Resident #46 updated 08/22/23, revealed the resident had suspected osteomyelitis infection of the sacrum/coccyx. Interventions included the following: administer antibiotic as per physician orders, treatment as ordered, monitor for symptoms/complications of osteomyelitis such as: bone pain, excessive sweating, fever/chills, general discomfort/malaise, local swelling/redness/warmth, wound drainage/pus, and pain at site of infection. Observation of wound care for Resident #46 on 08/23/23 at 11:58 A.M. completed by Registered Nurse (RN) #910, revealed the nurse did not assess the resident's pain level prior to or during the would care dressing change. Resident #46 moaned while nurse was removing packing from the deep stage IV pressure ulcer on the resident's sacrum. RN #910 apologized to the resident for the pain. State Tested Nursing Assistant (STNA) #330 was assisting the nurse with positioning the resident during wound care. Resident #46 was on her right side and was facing STNA #330. When RN #910 cleansed the inside of the wound and began to pack the wound with Betadine-soaked gauze, the resident moaned more loudly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366316 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 366316 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seven Acres Senior Living at Clifton 476 Riddle Road Cincinnati, OH 45220 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 0697 Level of Harm - Actual harm Residents Affected - Few and complained of pain. STNA #330 comforted the resident and told her to squeeze her hand. The Surveyor questioned the resident regarding her pain level and the resident said her pain was eight (pain scale where zero = none and 10 = severe). RN #910 then applied an abdominal (ABD) pad to cover the wound and asked the resident if she would like pain medication before continuing with wound care, and the resident confirmed she would like to have a dose of the Percocet. Continued observation of wound care revealed Resident #46 was not administered any medications for pain relief. Interview with RN #910 on 08/23/23 at 12:18 P.M. confirmed the last time Resident #46 had received any pain medication was on 08/22/23 at 9:30 A.M. RN #910 confirmed she had not assessed Resident #46 for pain prior to the wound dressing procedure. RN #910 confirmed Resident #46 should be assessed and offered pain medication prior to the dressing change to her stage IV pressure ulcer. Interview with Director of Nursing (DON) on 8/23/23 at 1:37 P.M. confirmed Resident #46 should be assessed for pain prior to and during wound care. DON indicated Resident #46 should have received pain medication approximately 45 minutes prior to the wound care procedure due to the severity of the resident's wound. Review of the controlled substance sheets for Resident #46 received on 08/25/23, revealed no documented evidence the resident was administered a PRN Percocet or Tylenol during the resident's dressing change to her stage IV sacral ulcer on 08/23/23. Review of the online resource NPUAP resource titled Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline at (https://npiap.com/general/custom.asp?page=2014Guidelines) downloaded on 08/23/23, revealed on page 144 that evidence suggests that individuals with Category/Stage IV pressure ulcers experience more pain than individuals with lower Category/Stage ulcers. Review of page 161 revealed staff should organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Pain management included performing care after administration of pain medication to minimize pain experienced and interruptions to comfort for the individual. Review of page 163 revealed staff should use adequate pain control measures, including additional dosing, prior to commencing wound care procedures as wound care procedures including wound manipulation, wound cleansing, debridement, and dressing changes are painful. This deficiency represents non-compliance investigated under Complaint Number OH00143101. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366316 If continuation sheet Page 6 of 6