Inspection·August 15, 2019

F 0609 were filed regarding the incident between Resident #45 and Resident #58. Level of Harm - Minimal harm or potential for actual harm 2. Review of record revealed Resident #106 was admitted [DATE] with diagnoses which included anxiety disorder and history of transient ischemic attacks. Review of the MDS assessment, dated 07/23/19, revealed the resident had mild cognitive impairment, required extensive assistance of two staff with activities of daily living, and was coded as negative for behavioral problems, including hallucinations and delusions. Residents Affected - Few Review of the nursing progress notes, dated 06/11/19 at 12:00 P.M. entered by Registered Nurse (RN) #20, revealed the resident alleged to staff that she was touched inappropriately by an unknown male, that vital signs were taken, that the resident's physician was notified, and that the facility's intervention regarding the resident's allegations were to provide the resident with an opportunity for positive interaction and attention and to stop and talk with resident when staff pass by. Review of the written statement per State Tested Nursing Assistant (STNA) #394, dated 06/11/19, revealed Resident #106 told STNA that a man came her into her room and told her he needed to do an exam on her, that she took her clothes off and when she asked why, he said it was his job. Further review of statement revealed that Resident #106 alleged that the unknown male had his hand in places it had no business, that he had put his fingers in her vagina and he did more to her than her own husband had done. Review of the written statement per Social Worker (SW) #500, dated 06/11/19, regarding Resident #106's allegation of being inappropriately touched by an unknown male revealed that resident appeared to be fine, that resident was assessed by the nurse practitioner (NP) on 06/11/19, that resident has history of making false allegations, and that the NP's assessment showed no signs of trauma. Review of the interdisciplinary note per Nurse Practioner (NP) #600, dated 06/11/19, revealed revealed NP assessed the resident, that resident had no recollection of making allegations of being touched inappropriately, and that resident has a history of confusion, past physical abuse and of making false allegations. Review of the progress note per NP #600, dated 06/12/19, revealed the resident was seen for follow up on staff's report from yesterday when the resident felt she was violated sexually. Further review of the note revealed NP examined the resident, that the review of systems was normal and that on 06/12/19 the resident denied any concerns. Review of the Self-Reported Incidents (SRIs) for the facility dated 06/11/19 through 08/13/19 revealed no reports regarding an alleged sexual abuse alleged by Resident #106. Interview on 08/13/19 at 3:25 P. M. with RN #20 confirmed she interviewed Resident #106 after learning that the resident had alleged being inappropriately touched by an unknown male. RN #20 confirmed that Resident #106's story was inconsistent, that resident had a history of adult abuse, that the resident did not recall making the allegation, and that the nurse reported the allegation to the Administrator and the Director of Nursing (DON). Interview with the Administrator on 08/13/19 at 5:00 P.M. confirmed that the facility took the following actions on 06/11/19 following Resident #106's allegation of being inappropriately touched: nursing and social services interviewed Resident #106, the attending physician was notified of the allegation, ensured no male nursing assistants were in the facility, obtained statements from staff and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 2 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0609 other residents regarding the allegation, nurse practitioner interviewed the resident. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) and the Administrator on 08/13/19 at 6:36 P.M. confirmed the allegation of sexual abuse by Resident #106 was not reported to ODH as an allegation of sexual abuse. Residents Affected - Few Interview with NP #600 on 08/14/19 at 9:33 A.M. confirmed that on 06/11/19 staff had informed that Resident #106 had alleged that an unknown male had touched her inappropriately. NP further confirmed that she went to speak to the resident, that resident had no recollection of the incident, and that she did not perform a physical examination of the resident until the following morning on 06/12/19. 3. Review of the record for Resident #76 revealed an admission date of 11/27/16 with diagnoses which included dementia with behavioral disturbance. Review of the MDS assessment, dated 07/10/19, revealed the resident was cognitively impaired, required extensive assistance of two staff with activities of daily living, used a wheelchair for mobility, and was coded as negative for the presence of behavioral symptoms. Review of the nurse progress note, dated 04/28/19 at 6:53 A.M. written by Licensed Practical Nurse (LPN) #169, revealed the resident was being verbally abusive and was observed using her wheelchair and rolling over another resident's feet on purpose. Review of record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and history of transient ischemic attacks. Review of the MDS assessment for Resident #106 dated 07/23/19 revealed resident had mild cognitive impairment, required extensive assistance of two staff with activities of daily living, and was coded as negative for behavioral problems, including hallucinations and delusions . Review of the nurse progress notes for Resident #106 from 04/28/19 through 08/15/19 revealed notes were silent regarding Resident #76 rolling over resident's feet and/or any interventions to protect resident or assess for possible injuries. Review of the facility's Self-Reported Incidents (SRIs), dated 06/11/19 through 08/13/19, revealed there were no reports regarding alleged physical resident to resident abuse against Resident #106. Interview with LPN #168 on 08/13/19 at 12:35 P.M. confirmed that she witnessed Resident #76 deliberately rolling over Resident #106's feet on 04/28/19, that she told Resident #76 to stop but the resident didn't listen and did it again. LPN #168 confirmed that she did not believe Resident #106 was injured but that she did not document a physical assessment of the resident and that she did not report the incident to administration. Interview with the Administrator on 08/13/19 at 4:37 P.M. confirmed that she was not notified of the incident in which Resident #76 rolled over Resident #106's feet on 04/28/19 until sometime on 04/29/19 and that the facility took the following actions following the report: random interviews of other residents on the floor, notification of Resident #76's representative, interviews of staff. Further interview with the Administrator confirmed the facility did not report or investigate the incident as an allegation of potential resident to resident physical abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 3 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0609 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Abuse, Neglect, and Misappropriation, dated 11/2016, revealed the facility would investigate and report to ODH all allegations of abuse, that resident to resident altercations would be investigated, and that a cognitively impaired resident could possibly commit an act of abuse. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 4 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview and review of facility policy, the facility failed to thoroughly investigate allegations of verbal, sexual and physical abuse to the Ohio Department of Health (ODH). This affected three (Residents #58, #76 and #106) of five residents reviewed for abuse. The census was 134. Residents Affected - Few Findings include: 1. Review of record revealed Resident #58 was admitted on [DATE] with a diagnoses which included end stage renal disease. Review of the Minimum Data Set (MDS) assessment, dated 07/03/19, revealed the resident was cognitively impaired and was coded as negative for behavioral symptoms. Review of record revealed Resident #45 was admitted on [DATE] with diagnoses which included congestive heart failure. Review of the MDS assessment, dated 07/01/19, revealed the resident was cognitively intact, required supervision with activities of daily living, and was coded as negative for behavioral symptoms. Review of progress notes for Resident #45, dated 08/05/19, revealed the resident made threats of physical injury to his roommate, Resident #58, that residents were immediately separated, and that Resident #45 was moved to a private room to avoid any potential physical altercations. Further review of the note revealed that Resident #45 acknowledged making threats to Resident #58 and that facility staff educated Resident #45 that he was not permitted to make threats towards others, and that Resident #45 verbalized agreement. Interview with Resident #45 on 08/12/19 at 3:37 P.M. confirmed he had made threats of physical harm towards his former roommate, Resident #58 on 08/05/19 and that was why he had been moved to his current room. Interview with Registered Dietitian (RD) #74 on 08/13/19 at 4:31 P.M. confirmed that Resident #45 made verbal threats to physically harm (beat him up, punch him in the face) Resident #58. RD #74 confirmed that she had notified nursing immediately and ensured the residents were separated. Interview with the Administrator on 08/13/19 at 5:07 P.M. confirmed the facility had not investigated Resident #45's verbal threats to Resident #58 as a potential instance of resident abuse. 2. Review of record revealed Resident #106 was admitted [DATE] with diagnoses which included anxiety disorder and history of transient ischemic attacks. Review of the MDS assessment, dated 07/23/19, revealed the resident had mild cognitive impairment, required extensive assistance of two staff with activities of daily living, and was coded as negative for behavioral problems, including hallucinations and delusions. Review of the nursing progress notes, dated 06/11/19 at 12:00 P.M. entered by Registered Nurse (RN) #20, revealed the resident alleged to staff that she was touched inappropriately by an unknown male, that vital signs were taken, that the resident's physician was notified, and that the facility's intervention regarding the resident's allegations were to provide the resident with an opportunity for positive interaction and attention and to stop and talk with resident when staff pass by. Review of the written statement per State Tested Nursing Assistant (STNA) #394, dated 06/11/19, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 5 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed Resident #106 told STNA that a man came her into her room and told her he needed to do an exam on her, that she took her clothes off and when she asked why, he said it was his job. Further review of statement revealed that Resident #106 alleged that the unknown male had his hand in places it had no business, that he had put his fingers in her vagina and he did more to her than her own husband had done. Review of the written statement per Social Worker (SW) #500, dated 06/11/19, regarding Resident #106's allegation of being inappropriately touched by an unknown male revealed that resident appeared to be fine, that resident was assessed by the nurse practitioner (NP) on 06/11/19, that resident has history of making false allegations, and that the NP's assessment showed no signs of trauma. Review of the interdisciplinary note per Nurse Practioner (NP) #600, dated 06/11/19, revealed revealed NP assessed the resident, that resident had no recollection of making allegations of being touched inappropriately, and that resident has a history of confusion, past physical abuse and of making false allegations. Review of the progress note per NP #600, dated 06/12/19, revealed the resident was seen for follow up on staff's report from yesterday when the resident felt she was violated sexually. Further review of the note revealed NP examined the resident, that the review of systems was normal and that on 06/12/19 the resident denied any concerns. Interview on 08/13/19 at 3:25 P. M. with RN #20 confirmed she interviewed Resident #106 after learning that the resident had alleged being inappropriately touched by an unknown male. RN #20 confirmed that Resident #106's story was inconsistent, that resident had a history of adult abuse, that the resident did not recall making the allegation, and that the nurse reported the allegation to the Administrator and the Director of Nursing (DON). Interview with the Administrator on 08/13/19 at 5:00 P.M. confirmed that the facility took the following actions on 06/11/19 following Resident #106's allegation of being inappropriately touched: nursing and social services interviewed Resident #106, the attending physician was notified of the allegation, ensured no male nursing assistants were in the facility, obtained statements from staff and other residents regarding the allegation, nurse practitioner interviewed the resident. Interview with the Director of Nursing (DON) and the Administrator on 08/13/19 at 6:36 P.M. confirmed that Resident #106 was not sent to the hospital for an evaluation or physical examination and that law enforcement was not notified of resident's allegation. Interview with NP #600 on 08/14/19 at 9:33 A.M. confirmed that on 06/11/19 staff had informed that Resident #106 had alleged that an unknown male had touched her inappropriately. NP further confirmed that she went to speak to the resident, that resident had no recollection of the incident, and that she did not perform a physical examination of the resident until the following morning on 06/12/19. 3. Review of the record for Resident #76 revealed an admission date of 11/27/16 with diagnoses which included dementia with behavioral disturbance. Review of the MDS assessment, dated 07/10/19, revealed the resident was cognitively impaired, required extensive assistance of two staff with activities of daily living, used a wheelchair for mobility, and was coded as negative for the presence of behavioral symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 6 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the nurse progress note, dated 04/28/19 at 6:53 A.M. written by Licensed Practical Nurse (LPN) #169, revealed the resident was being verbally abusive and was observed using her wheelchair and rolling over another resident's feet on purpose. Review of record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and history of transient ischemic attacks. Review of the MDS assessment for Resident #106 dated 07/23/19 revealed resident had mild cognitive impairment, required extensive assistance of two staff with activities of daily living, and was coded as negative for behavioral problems, including hallucinations and delusions . Review of the nurse progress notes for Resident #106 from 04/28/19 through 08/15/19 revealed notes were silent regarding Resident #76 rolling over resident's feet and/or any interventions to protect resident or assess for possible injuries. Interview with LPN #168 on 08/13/19 at 12:35 P.M. confirmed that she witnessed Resident #76 deliberately rolling over Resident #106's feet on 04/28/19, that she told Resident #76 to stop but the resident didn't listen and did it again. LPN #168 confirmed that she did not believe Resident #106 was injured but that she did not document a physical assessment of the resident and that she did not report the incident to administration. Interview with the Administrator on 08/13/19 at 4:37 P.M. confirmed that she was not notified of the incident in which Resident #76 rolled over Resident #106's feet on 04/28/19, until sometime on 04/29/19 and that the facility took the following actions following the report: random interviews of other residents on the floor, notification of Resident #76's representative, interviews of staff. Further interview with the Administrator confirmed the facility did not obtain written statements from staff on the day of the allegation, did not document a physical assessment of Resident #106, and did not report or investigate the incident as an allegation of potential resident to resident physical abuse. Review of the facility policy titled Abuse, Neglect, and Misappropriation, dated 11/201,6 revealed the facility would investigate all allegations of abuse including resident-to-resident abuse and sexual abuse which was defined as nonconsensual sexual contact of any kind with a resident. Further review of the policy revealed that residents would be assessed for possible injury by a nurse following allegations of abuse and that the assessment would include a full body assessment and referred to hospital if indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 7 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 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, record review and staff interviews, the facility failed to ensure pressure reduction devices were in place. This affected one (Resident #94) of four reviewed for pressure injury. The facility identified all 134 residents residing in the facility were receiving preventative skin care. Residents Affected - Few Findings include: Review of Resident #94's medical record revealed an admit date of 06/16/19 with diagnoses including urinary tract infection, obstructive uropathy, dementia and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had severe cognitive impairment, required extensive assistance of two staff members for bed mobility and transfers. Review of the physician orders, dated 07/19/19 revealed Prevalon boots (aid in pressure reduction) to be worn. Review of the [NAME] (care plan interventions for state tested nurse assistants) dated 08/09/19 indicated - offload heels with pillows as tolerated. The [NAME] was silent to Prevalon boots ordered by the physician. Review of the skin risk assessment, dated 08/09/19, revealed Resident #94 was at increased risk for pressure ulcer sores. A weekly skin note, dated 08/13/19, indicated Resident #94 had altered skin on his buttocks and groin. Observation on 08/12/19 at 3:07 P.M. of Resident #9 lying in bed with heels lying directly on the mattress. Prevalon boots were noted inside the open closet. Subsequent observation on 08/14/19 at 3:14 P.M. revealed Resident #94 was lying in bed asleep with heels lying directly on mattress. Interview on 08/12/19 at 3:15 P.M. with Licensed Practical Nurse (LPN) #160 who denied Resident #94 had any interventions to prevent skin injury. Interview on 08/14/19 at 5:48 P.M. with Registered Nurse (RN) #280 who verified Resident #94 was not wearing Prevalon boots and no documentation of refusals were documented. Interview on 08/15/19 at 2:31 P.M. with State Tested Nurse Assistant #398 and LPN #136 who both denied any knowledge of pressure reduction items ordered for Resident #94 and stated they had not attempted to offload his heels or apply any boots. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 8 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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, observations, and staff interviews, the facility failed to use safety device equipment as care planned to prevent falls. This affected two (Residents #58 and #94) of five residents reviewed for falls. The in-house facility census was 134. Findings include: 1. Record review for Resident #58 revealed the resident was admitted to the facility on [DATE]. Diagnoses included syncope, hyperglycemia, diabetes mellitus, atrial fibrillation, hypertension, hemiplegia, chronic obstructive pulmonary disease, arthropathy, glaucoma and altered mental status. Review of the quarterly Minimum Data Set assessment, dated 07/03/19, revealed Resident #58 has mild to moderate cognitive deficits and required extensive assistance with activities of daily living. Review of the care plan, dated 04/11/19, revealed Resident #58 was at risk for falls related to gait/balance problems, side effects of medications, impaired mobility, new environment, hemiparesis, altered mental status, incontinence and blind. An intervention, dated 10/27/17, was to place fall mats/floor mats to bedside. Review of the admission Fall Risk Scale, dated 07/02/19, revealed a score of 12.0 indicating the resident was at an increased risk for falls. Observation on 08/12/19 at 1:59 P.M. revealed Resident #58 was in bed, and the floor mats were leaning against the wall. Interview on 08/12/19 at 2:13 P.M. with Licensed Practical Nurse (LPN) #128 verified that the fall mats were not in place as care planned. Observation on 08/12/19 at 5:42 P.M. revealed Resident #58 was still in his bed and fall mats were still leaning against the wall and not in place beside the beds. Interview on 08/12/19 at 5:48 P.M. with the Director of Nursing (DON) verified that the fall mats were not in place as care planned. 2. Record review for Resident #94 revealed an admit date of 06/16/19. Diagnoses included urinary tract infection, atrial fibrillation, heart disease, dementia and hypertension. Review of the MDS assessment, dated 07/19/19, revealed the resident had severe cognitive impairment, required extensive assistance of two staff members for bed mobility, transfers and toileting. Review of the physician orders, dated 07/19/19, revealed orders for anti-rollbacks to wheelchair and anti-tippers to the back of the wheelchair. Review of the Kardex (state tested nursing aide care plan for the resident), dated 08/09/19, indicated these same items. Observation on 08/12/19 at 3:07 P.M. of Resident #94 lying in bed. A wheelchair beside the bed had a name band on the left arm displaying Resident #94's name. The wheelchair did not have anti-rollbacks or anti-tippers attached. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 9 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/12/19 at 3:19 P.M. with Unit Manager Register Nurse #296 reported the wheelchair was in use for Resident #94 and verified the anti-tippers and anti-rollbacks were not attached. RN #296 stated they did not get attached after he returned from the hospital and she would have them attached as soon as possible. Interview with State Tested Nurse Assistant (STNA) #398 who denied any knowledge of fall prevention items ordered for Resident #94. Event ID: Facility ID: 366380 If continuation sheet Page 10 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation and staff interview, the facility failed to label resident oxygen tubing and humidification bottles with the date it was initiated. This affected one (Resident #92) of three residents reviewed for respiratory care. The facility identified 38 residents on oxygen use. The facility census was 134. Residents Affected - Few Findings include: Record review for Resident #92 revealed an admission date of 07/10/19 with diagnoses which included chronic respiratory failure. Review of the Minimum Data Set (MDS) assessment, dated 08/05/19, revealed the resident was cognitively intact and required extensive assistance of two staff with activities of daily living. Review of the resident's physician orders, dated 07/29/19, revealed an order the resident may use oxygen at two liters per minute per nasal cannula as needed for shortness of breath. Observation of Resident #92 on 08/12/19 at 9:54 A.M. revealed the resident had oxygen in place at two liters per nasal cannula with humidification. The oxygen tubing and the humidification bottle was undated. Interview with Licensed Practical Nurse (LPN) #166 on 08/12/19 at 9:54 A.M. confirmed that neither the oxygen tubing nor the humidification bottle for Resident #92 were dated and could not determine when they had been initiated for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 11 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on record review, dialysis staff interview and resident and staff interview, the facility failed to assess the resident's weight before providing peritoneal dialysis and failed to ensure medication was given per physician's order. This affected one (Resident #9) of one resident reviewed for peritoneal dialysis. The facility identified 10 residents on dialysis services. Residents Affected - Few Findings include: Review of Resident #9's medical record revealed an admission date of 02/08/19. Diagnoses included diabetes mellitus, anemia, congestive heart failure and end stage renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/05/19, the resident's cognition was intact and there were no refusal of care or behaviors. The MDS also revealed assist of one was required for bathing, toileting, but supervision only for other activities of daily living. Review of the care plan, dated 02/08/19, had a focus for peritoneal dialysis and interventions that included administer medications as indicated, monitor for signs/symptoms of fluid overload including increased weight. Review of the Medication Administration Record (MAR), dated 05/2019, revealed Epogen 24000 units ordered 04/24/19 for every 14 days initialed on 05/07/19 and 05/22/19 as not administered with the reason documented as medication not available. Review of the MAR, dated 06/2019, revealed Epogen 40000 units ordered on 06/11/19 for every 14 days initialed on 06/11/19 as not administered with the reason documented as medication not available. Review of the MAR, dated 07/2019, revealed Epogen 15000 units ordered on 07/26/19 for every Monday, Wednesday, Friday initialed on 07/26/19 as not administered with the reason as medication not available. Review of the electronic health record and Treatment Administration Record (TAR), dated 07/2019, revealed the resident was to be weighed daily. The resident was not weighed 12 of the 31 days on the following dates: 07/07, 07/10, 07/12, 07/13, 07/15, 07/19, 07/20, 07/23, 07/24, 07/27, 07/29 and 07/30. Interview with Resident #9 on 08/12/19 at 3:55 P.M. reported her weights were not assessed prior to dialysis being initiated by the nurses. She reported asking the nurses about the weights and reported she was told her weight was fine. She also complained of not receiving Epogen injections stating, they kept saying they couldn't find the medicine. Resident #9 stated she had complained about the Epogen at her last care conference in May and reported she was receiving the medication more frequently since she kept the Epogen in her refrigerator in her room, but weights were still not done. Interview on 08/14/19 at 4:27 P.M. with Dialysis Case Manager #411 reported she had communicated with the facility frequently with concerns of Epogen medication not being received due to Resident #9's reports and a large decrease in her hemoglobin (blood count). CM #411 stated she and the nephrologist were comfortable the Epogen was received per order only the last two weeks. She denied being aware of weights not being obtained. Interview on 08/14/19 at 12:30 P.M. with Unit Manager Registered Nurse (RN) #296 who stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 12 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0698 Level of Harm - Minimal harm or potential for actual harm additional weights were present in another electronic health system that was not accessible to surveyors. She verified that even with the additional weights she located weights were not documented on 07/07, 07/10, 07/12, 07/13, 07/15, 07/19, 07/20, 07/23, 07/24, 07/27, 07/29 and 07/30/19. RN #296 stated she was aware of Epogen not being administered as ordered before she had accepted the Unit Manager position, but she now worked closely with the dialysis case manager to ensure availability of Epogen. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 13 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on record review and staff interview, the facility failed to administer physician ordered intravenous antibiotics. This affected one (Resident #71) of three residents reviewed for infections and had potential to affect three residents the facility identified as receiving intravenous antibiotics. The facility census was 134. Findings include: Review of Resident #71's medical record revealed an admit date of 06/10/19. Diagnoses included stroke, diabetes, anemia, urinary tract infection, heart failure, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/29/19, revealed the resident had intact cognition. Review of the resident's care plan, dated 07/30/19, revealed a focus of a blood infection with interventions including to administer antibiotics per physician orders. Review of the resident's Medication Administration Record (MAR), dated 08/01/19, revealed the physician ordered for Vancomycin (antibiotic) 500 milligrams every other day. Review of the MAR indicated Vancomycin was not administered on 08/03/19 and stated see the notes, on 08/05/19 it was marked the resident refused, on 08/11/19 it was marked the medication was not available and the MAR was silent on 08/07/19 and 08/09/19. Interview on 08/15/19 at 3:20 P.M. with Unit Manager Registered Nurse (RN) #296 reported the nurse on 08/09/19 forgot to sign the Vancomycin as given and would do a late entry. RN #296 reported on 08/09/19 the Vancomycin was not administered since the pump was not functioning and pharmacy was contacted to send a new pump that was delivered that evening. Additionally, RN #296 was unable to provide documentation why Vancomycin was not administered on 08/03/19 and 08/11/19. RN #296 stated she had no documentation of the physician being contacted for the missed doses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 14 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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, staff interview and facility policy review, the facility failed to provide a stop date on psychotropic medications. This affected two (Resident #45 and #90) of seven residents reviewed for unnecessary medications. The facility in-house census was 134. Findings include: 1. Record review for Resident #90 on 08/14/19 revealed Resident #90 was admitted on [DATE]. Diagnoses included anxiety and depression. Review of the admission Minimum Data Set (MDS) assessment, dated 07/17/19, revealed Resident #90 has severe cognitive deficits. Review of the physician order, dated 07/16/19 revealed to give Alprazolam (anti-anxiety) 0.25 milligrams (mg.) every eight hours as needed for anxiety with no end date. Review of the Medication Administration Review (MAR), dated 07/2019, revealed Alprazolam 0.25 mg. was given on the following dates 07/17/19, 07/18/19, 07/19/19, 07/20/19, 07/21/19, 07/23/19, 07/24/19, 07/25/19, 07/26/19, 07/28/19 and 07/30/19. Review of the MAR dated for 08/2019 revealed the medication was given on 08/01/19, 08/03/19, 08/04/19, 08/06/19, 08/09/19, 08/10/19, 08/11/19, 08/12/19 and 08/13/19. Interview on 08/14/19 at 12:07 P.M. with the Director of Nursing (DON) verified there was no end date for the use of Alprazolam 0.25 mg as needed. Interview on 08/15/19 at 1:42 P.M. with the Director of Nursing and Corporate Registered Nurse #13 verified that the signature was a valid physician order and the order had not been followed resulting with no end or stop date. 2. Record review for Resident #45 revealed the resident was admitted to the facility on [DATE] with a diagnosis of congestive heart failure. Review of the MDS assessment, dated 07/01/19, revealed the resident was cognitively intact and was coded as negative for behavioral symptoms. Review of the resident's physician orders, dated 07/17/19, revealed an order for the anti-anxiety medication clonazepam to be given as needed. The order did not include a stop date. Review of the Medication Administration Record (MAR) for Resident #45 revealed the resident received as needed doses of clonazepam on the following dates: 07/23/19, 07/24/19, 07/25/19, 07/27/19, 08/01/19, 08/04/19, 08/07/19, 08/08/19, 08/09/19, 08/10/19, 08/13/19 and 08/14/19. Review of the consultant pharmacist recommendation, dated July 2019, regarding the as needed clonazepam order for Resident #45 revealed a recommendation that as needed orders for psychotropic medications were limited to fourteen days and offered the following alternatives for the prescriber to consider: to discontinue the order, add a stop date within fourteen days of the order or if extending the order beyond fourteen days, document the rationale and add a stop date longer than 14 days. Further review of the consultant pharmacist recommendation for Resident #45 revealed the physician signed and dated the recommendation on 07/24/19 and noted that the resident refused changes in medications, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 15 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 but did not indicate a stop date for the order. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 08/15/19 at 9:45 A.M. confirmed that the as needed clonazepam order for Resident #45, dated 07/17/19, did not have a stop date and that as needed psychotropic medications should have a stop date. Residents Affected - Few Review of the facility policy titled Psychotropic Medication Management, dated 10/2017, revealed that if a psychotropic medication is ordered on an as needed basis, the prescribing practitioner should document the rationale for use and indicate the duration for the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 16 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, observation, staff interview, and review of facility policy, the facility failed to discard expired medications and failed to appropriately store medications regarding refrigeration. This affected three of four medication carts observed. The facility had eight medication carts. This affected three residents (Residents #57, #90 and #320) observed to have expired and/or improperly stored medications stored in the medication carts. The facility census was 134. Findings include: 1. Record review for Resident #57 revealed an admission date of 03/04/19 with a diagnosis of diabetes. Review of the physician orders, dated 06/18/19, revealed an order for Lantus insulin to be given by subcutaneous injection 20 units every evening. Observation of the Lantus insulin pen in the medication cart for Resident #57 on 08/14/19 at 2:39 P.M. with Registered Nurse (RN) #280 revealed the insulin had marked with an expiration date of 08/13/19. Interview on 08/14/19 at 2:39 P.M. with RN #280 confirmed the Lantus insulin pen for Resident #57 was expired and should be discarded. 2. Record review for Resident #90 revealed an admission date of 07/17/19 with a diagnosis of gastro-esophageal reflux disease. Review of the physician orders, dated 07/18/19, revealed an order for bismuth subsalicylate (also know as Pepto-Bismol) 30 milliliters as needed for loose stool. Observation of Pepto-Bismol in the medication cart on 08/14/19 at 8:28 A.M. with Licensed Practical Nurse (LPN) #122 revealed an opened bottle marked as opened by the staff on 07/19/19 with a manufacturer's expiration date of June 2019. Interview on 08/14/19 at 8:28 A.M. with LPN #122 confirmed the bottle had been opened by the staff and marked as opened on 07/19/19, but that the manufacturer's expiration date for the Pepto-Bismol for Resident #90 was June 2019 and that the medication was expired and should be discarded. 3. Record review for Resident #320 revealed an admission date of 08/01/19 with a diagnosis of cirrhosis of the liver. Review of the physician orders, dated 08/01/19, revealed an order for carafate liquid suspension 10 milliliters by mouth four times per day. Observation of the carafate liquid in the medication cart for Resident #320 on 08/14/19 at 2:40 P.M. with Registered Nurse (RN) #280 revealed the bottle was marked per the dispensing pharmacy that it should be stored in the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 17 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 08/14/19 at 2:40 P.M. with RN #280 confirmed the bottle of carafate liquid for Resident #320 was being stored in the medication cart and should be stored in the refrigerator. Review of the facility policy titled Medication Storage, dated 08/2018, revealed that medication should not be retained or used for resident beyond the manufacturer's expiration date and that medications with a shortened expiration date once opened should be discarded per the manufacturer/supplier's recommendations with respect to expiration dates for opened medications. Event ID: Facility ID: 366380 If continuation sheet Page 18 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident and staff interview, the facility failed to offer and arrange for dental consultation for one (Resident #45) of four residents reviewed for dental concerns. The facility census was 134. Residents Affected - Few Findings include: Record review for Resident #45 revealed the resident was admitted on [DATE] with diagnoses which included congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 07/01/19, revealed the resident was cognitively intact and was not coded for dental concerns. Review of the care plan, initiated on 01/25/19, revealed the care plan was silent regarding resident's dental status or any dental needs. Review of the physician's order, dated 01/25/19, revealed an order that resident may be seen by the dentist. Review of the record for Resident #45 revealed no written record of consent or declination of dental visits. Interview and observation of Resident #45 on 8/13/19 at 3:36 P.M. revealed the resident had multiple missing teeth and several teeth that appeared to show signs of decay. The resident stated she had multiple missing teeth and several teeth that appeared to show signs of decay. The resident denied any current mouth pain, he had not seen a dentist or been offered an opportunity to see a dentist since his admission to the facility, and that he would like to see a dentist to evaluate his missing and decaying teeth. Interview on 08/14/19 at 10:51 A.M. with Medical Records Coordinator #176 confirmed the facility had no record that Resident #45 had seen a dentist or had been offered an opportunity to see a dentist since his admission to the facility. Interview on 08/14/19 at 12:04 P.M. with the Director of Nursing (DON) confirmed the facility had a dentist that visited the facility on a regular basis and that residents were seen by the dentist if they requested it or if they had a dental problem. DON further confirmed that all residents and/or resident representatives were to be offered a consent form for routine dental visits from the facility dentist on which the resident and/or resident's representative could consent or decline dental visits. DON confirmed that the facility did not have a consent form for Resident #45 indicating whether the resident wanted dental visits or not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 19 of 20 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 366380 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Indianspring of Oakley 4900 Babson Place Cincinnati, OH 45227 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 observation, record review and staff interview, the facility failed to follow infection control measures for a resident's urinary catheter. This affected one (Resident #94) of three residents reviewed for urinary catheters. The facility identified three residents with urinary catheters. Residents Affected - Few Findings include: Review of Resident #94's medical record revealed an admit date of 6/16/19 with diagnoses including urinary tract infection, prostate enlargement and obstructive uropathy. Review of the Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had severe cognitive impairment. Review of the state tested nursing aide [NAME], dated 08/09/19, revealed to position the catheter bag and tubing below the level of the bladder and off of the floor. Observation on 08/12/19 at 3:07 P.M. of Resident #9 revealed he was lying in bed and the resident's urinary catheter bag was lying on the floor. Interview on 08/12/19 at 3:15 P.M. with Licensed Practical Nurse #160 and Unit Manager, Registered Nurse (RN) #296 and RN #296 verified Resident # 94's urinary bag was lying on the floor and stated the bag did not have a hook to hang it. Observation of Resident #94 on 08/14/19 at 1:22 P.M. while at lunch revealed the urinary catheter tubing lying on the floor under his wheelchair. At the time of observation, State Tested Nurse Assistant (STNA) #398 verified the urinary catheter tubing was dragging on the floor and stated she had tried to curl it up but his pant leg caused the tube to drag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 20 of 20