Health inspection·July 13, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure orders from a wound clinic were implemented and followed for a resident with multiple diabetic wounds. This affected one (#70) of one resident reviewed for diabetic ulcers. The facility census was 113. Residents Affected - Few Findings include: Review of Resident #70's medical record revealed Resident #70 was re-admitted to the facility on [DATE]. Diagnoses included morbid obesity due to excess calories, chronic diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, gangrene, type II diabetes mellitus with diabetic chronic kidney disease, and end stage renal disease. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had moderate cognitive impairment. Resident #70 required extensive assistance of two staff for bed mobility, transfer, and toilet use. Review of the care plan revealed Resident #70 had venous/stasis ulcer to his bilateral feet/heels and right ankle related to his decreased functional ability, decreased sensory ability, and impaired/decreased mobility. Interventions included administering treatments as ordered and monitor for effectiveness. He also had a care plan regarding his surgical site to the left transmetatarsal amputation (TMA). The interventions included administering treatments as ordered and monitor for effectiveness. Review of the physician order dated 05/15/23 revealed there was an order for the left dorsal foot to be cleansed with normal saline, pat dry, paint with betadine, and cover with adaptic cover with meplex. It was to be changed on night shift every Monday, Wednesday, and Friday for wound care. The physician order dated 06/16/23 revealed an order to apply Santyl Ointment 250 units/gram (Collagenase) to the left heel, left foot, and right heel topically every night shift every Monday, Wednesday, and Friday for wound care. Before applying, cleanse with normal saline and pat dry. After applying ointment cover with a 4x4 and abdominal pad, wrap with kerlix, and secure. Review of the Wound Care Clinic notes dated 06/19/23 revealed the wound center was following six diabetic ulcers Resident #70 had. The wound care orders dated 06/19/23 were for the TMA and left foot medial wounds to be cleansed with normal saline and pat dry. Apply a silver alginate to the wound beds. Cover with dry gauze, ABD, and roll gauze. Change the dressing Mondays, Wednesdays, and Fridays. There was also an order for the bilateral heels, fifth toe amputation, right ankle and right/left dorsal foot wounds to cleanse the wound with normal saline and pat dry. Apply medihoney to the eschar areas. Cover with dry gauze, ABD, and roll gauze. Change the dressing Mondays, Wednesdays, and Fridays. The Wound Care Clinic note dated 07/10/23 revealed to continue with the same orders as 06/19/23. There was no evidence the Wound Care Clinic orders were implemented for Resident #70 at the facility from 06/19/23 to 07/11/23. Interview with the Director of Nursing (DON) on 07/13/23 at 3:00 P.M. verified the wound clinic orders for Resident #70 dated 06/19/23 and 07/10/23 were not implemented for Resident #70 at the facility. Review of the policy titled Skin Integrity Team (SIT)-Skin Monitoring Process, last revised (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 2 of 7 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 07/13/2023 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 0684 01/2023, revealed once the skin rounds and wound progress notes are completed, the SIT meeting will occur. This was to include verifying the treatment orders, care plans, and skin rounds match. 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: 366380 If continuation sheet Page 3 of 7 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 07/13/2023 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 medical record review, staff interview, and policy review, the facility failed to ensure a new unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) was measured upon identification. This affected one (#13) of four residents reviewed for pressure ulcers. The facility identified nine residents with pressure ulcers. The facility census was 113. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 03/27/23. Diagnoses included pulmonary embolism, major depressive disorder, fibromyalgia, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of a nursing progress note dated 06/09/23 revealed an unstageable pressure area was observed on Resident #13's heel. The physician was notified and orders were received for a treatment to the newly identified area. There were no measurements of the wound and no description of the wound. Review of Resident #13's Wound Progress Note, dated 06/15/23, revealed the first measurement of the unstageable pressure ulcer on the left heel was measured on 06/15/23. Review of the plan of care dated 07/10/23 revealed Resident #13 had a pressure ulcer to the left heel related to impaired mobility. Interventions included to administer treatments as ordered and monitor effectiveness, assist with mobility, turning, and repositioning, and evaluate wound for size and depth and document progress on an ongoing basis. Interview on 07/13/23 at 1:18 P.M. with Registered Nurse (RN) #300 verified Resident #13's unstageable pressure area to the left heel was identified on 06/09/23 and had no documented measurements until 06/15/23. RN #300 verified the pressure area should have been measured at the time it was identified and stated she was unsure why it was not measured as the nurse who identified the area should have documented measurements. Review of the facility policy titled Skin Integrity Team (SIT)-Skin Monitoring Process, dated 01/2023, revealed during skin rounds, if a new, significant, skin issue is noted, including unstageable ulcers, the nurse will initiate a wound progress note and complete the wound progress portion to document the specifics of the significant skin issue. This deficiency represents non-compliance investigated under Complaint Number OH00144070. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 4 of 7 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 07/13/2023 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 medical record review, observations, staff interviews, and policy review, the facility failed to ensure the residents who were at risk for falling had their care-planned and/or physician ordered fall interventions in place. This affected three (#13, #42, and #62) of five residents reviewed for falls. The facility census was 113. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 03/27/23. Diagnoses included pulmonary embolism, insomnia, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the plan of care dated 05/03/23 revealed Resident #13 was at risk for falls related to gait/balance problems, side effects of medications, and incontinence. Interventions included anti-rollback to Resident #13's wheelchair. Observation on 07/13/23 at 10:39 A.M. revealed Resident #13's red emergency call light was activated outside of her room. Resident #13 was observed in the bathroom, seated on the commode, and her wheelchair directly in front of her. There were no anti-rollbacks observed on Resident #13's wheelchair. Further observation revealed no other wheelchairs in Resident #13's room nor outside of her room. Observation and interview on 07/13/23 at 10:42 A.M. revealed Physical Therapy Assistant (PTA) #301 entered Resident #13's room to answer the emergency call light. PTA #301 stated Resident #13 must have taken herself to the bathroom. PTA #301 verified Resident #13's wheelchair did not have anti-rollbacks in place. Interview on 07/13/23 at 10:53 A.M. with the Administrator verified Resident #13 had an active care plan intervention for anti-rollbacks to her wheelchair. 2. Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart disease, anxiety disorder, major depressive disorder, and restless leg syndrome. Review of the annual Minimum Data Set (MDS) assessment, dated 07/07/23, revealed Resident #42 had impaired cognition and required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Review of the physician orders dated 05/05/22 revealed Resident #42 had an order for fall mats to the sides of the bed. Review of the fall care plan, dated 07/07/23, revealed Resident #42 was at risk for falls related to gait/balance issues, history of falls, side effects of medication, and various health diagnoses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 5 of 7 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 07/13/2023 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 Her interventions included fall mats to the sides of her bed. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 07/13/23 at 9:10 A.M. with State Tested Nurse Aide (STNA) #61 confirmed Resident #42 should have a fall mat to each side of her bed. STNA #61 confirmed both fall mats were stacked on top of each other on the left side of the bed only. Resident #61 was lying in bed at the time of the observation. Residents Affected - Few 3. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, diabetes mellitus type II, severe obesity, vascular dementia, anxiety, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/21/23, revealed Resident #62 was mildly cognitively impaired and required extensive assistance from staff with bed mobility, transfers, dressing, and toilet use. Review of the fall care plan dated 04/2123 revealed Resident #62 was at risk for falls related to confusion, gait balance issues, impaired vision, history of falls, impulsive at times, and history of falls. Interventions included Dycem/posey grip to the seat of Resident #62's wheelchair. Interview on 07/12/23 at 10:02 A.M. with Assistant Director of Nursing (ADON) #300 confirmed Resident #62 required dycem posey grip to the seat of her wheelchair as indicated by an active physician order and confirmed it was located on the care plan. Interview and observation on 07/12/23 at 10:28 A.M. revealed State Tested Nurse Aide (STNA) #198 utilized a gait belt and assisted Resident #62 from her wheelchair. Licensed Practical Nurse (LPN) #198 was standing behind Resident #62's wheelchair and she confirmed Resident #62's wheelchair did not contain dycem or posey grip. Review of the facility policy titled Fall and Accident Management, dated 05/2016, revealed the facility will identify residents at risk for falls and interventions will be implemented and evaluated to reduce the risk of injuries, falls, or other accidents. This deficiency represents non-compliance investigated under Complaint Number OH00144070. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 6 of 7 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 07/13/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on record review, observation, staff interview, and policy review, the facility failed to ensure food was prepared in a manner to prevent potential contamination and spread of foodborne illness. This had the potential to affect all eight residents (#2, #3, #33, #37, #50, #53, #60, and #82) who received a pureed diet. The facility census was 113. Findings include: Observation on 07/12/23 at 11:18 A.M. revealed [NAME] #159 use her gloved hand to take four chicken breasts from a baking sheet, and placed them in a food processor, located directly next to the baking sheet, containing approximately ten additional chicken breasts. [NAME] #159 then reached on top of the steamer, located directly behind her, and obtained and donned a rubber oven mitt. [NAME] #159 pureed the chicken in the food processor, then removed the oven mitt, setting it on the counter. The arm of the oven mitt was observed sitting directly on top of two chicken breasts still remaining on the baking sheet. Interview on 07/12/23 at 11:20 A.M. with [NAME] #159 verified the arm of the oven mitt was resting directly on the chicken and removed the oven mitt and placed it on a cart beside the steamer. The cart contained a puddle of water, measuring approximately 10 inches by six inches. Continuous observation on 07/12/23 at 11:21 A.M. revealed [NAME] #159 changed her gloves, and placed the remaining chicken breasts from the baking sheet, including the two chicken breasts that had previously been in contact with the potentially contaminated oven mitt, into the food processor. [NAME] #159 pureed the chicken, then transferred into a pan for holding. Interview on 07/12/23 at 11:25 A.M. with [NAME] #159 verified the chicken, which the potentially contaminated oven mitt was resting on, was used in pureeing the remaining chicken. Review of the facility's residents diet list revealed Residents #2, #3, #33, #37, #50, #53, #60, and #82 received a pureed diet. Review of the facility policy titled Safe Food Handling and Storage, dated 06/2015, revealed proper handling of all foods is essential in preventing chemical, physical, or biological contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366380 If continuation sheet Page 7 of 7