Health inspection·July 5, 2023

F 0580 wheelchair incident on 06/27/23. A new order was obtained for an x-ray. Level of Harm - Minimal harm or potential for actual harm Review of Resident #29's imaging report dated 06/28/23 revealed Resident #29 had an acute appearing medial malleoli fracture with soft tissue swelling. Residents Affected - Few Review of Registered Nurse (RN) #902's witness statement dated 06/29/23, revealed while RN #902 was doing rounds on 06/27/23, Resident #29 called her into her room and asked her if the therapist told her what happened. RN #902 stated no and Resident #29 proceeded to tell her that while she was being wheeled to therapy in her wheelchair by the therapist, her right foot got caught under the wheelchair and the therapist did not know and kept wheeling. The resident then yelled for the therapist to stop, and the therapist then rolled her back to her room. RN #902 told Resident #29 she did not hear anything from the therapist and that she would reach out. The resident was still sitting in her chair. She raised her foot up and down and flexed back and forth and it was not red or swollen but was tender. RN #902 administered as needed pain medication and Resident #29 refused ice because of her arthritis. RN #902 asked the resident if she felt like she needed an x-ray and the resident stated no. RN #902 told Resident #29 she would get an x-ray if it was still bothersome when she came back to work on 06/28/23. As she went back to the nursing station, she saw the therapist in the hallway asked if she had something to say to her because Resident #29 told her what happened. The therapist stated I'm sorry, I forgot to tell you her foot was caught in her wheel underneath it. I meant to tell you. RN #902 proceeded to chart the situation and she was due back the next day. RN #902 gave report to the night shift nurse and the next morning the unit manager ordered the x-ray. Review of RN #902's disciplinary notice dated 06/29/23 revealed the nurse failed to follow proper procedures by not notifying the physician of an acute physical change or incident involving a resident and the family was not notified. Corrective action included immediate termination due to the nurse being aware of proper procedures of notifying the physician and family of acute changes in resident's the mental and physical status. Interview on 07/03/23 at 10:56 A.M. with OT #700, revealed she was wheeling Resident #29 down the hallway and Resident #29 was holding both of her legs up in the air. OT #700 stated the leg and footrests were not on the wheelchair due to Resident #29's legs not fitting properly on her current leg and footrests. OT #700 stated Resident #29 dropped her legs unexpectedly while she was pushing her down the hall and Resident #29's right leg and foot got caught and twisted in the wheelchair. Interview on 07/03/23 at 11:29 A.M. with Resident #29, revealed the resident broke her right ankle and stated the therapist was pushing her wheelchair on the way to therapy. Resident #29 reported she had her right leg up on her left leg because the right leg did not work well, and the right leg fell off the left leg and went under the wheelchair. Resident #29 stated she did not have leg and footrests on her wheelchair at the time of the incident because her legs did not stay on them correctly. Interview on 07/03/23 at 3:48 P.M. with the Director of Nursing (DON), revealed OT #700 was pushing Resident #29 down the hallway on 06/27/23 at an unknown time when the resident stated ouch. The DON reported OT #700 did not hear the resident and Resident #29 yelled out again and OT #700 stopped. The DON stated Resident #29's foot was twisted under the wheelchair. The DON reported OT #700 returned Resident #29 to her room and did not notify the nurse. Resident #29 was talking about the incident to another resident and RN #902 overheard them talking about the incident. The nurse assessed the resident for pain on 06/27/23 and Resident #29 had no initial signs of swelling and was given as needed pain medication. The DON stated RN #902 told Resident #29 that she would contact the doctor the next day if her foot hurt. The DON verified RN #902 did not contact the doctor, family, or management (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 2 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 06/27/23 regarding the incident which was against the facility's policy. The DON stated management found that RN #902 charted about the 06/27/23 incident on 06/28/23 and the family and physician were contacted based upon that progress note. Telephone interview on 07/05/23 at 12:07 P.M. with RN #902, revealed she was doing her rounds on 06/27/23 at around 5:30 P.M. or 6:00 P.M. when Resident #29 told her about the injury. Resident #29 told RN #902 that she was being pushed in a wheelchair by the therapist when her foot went underneath it because she did not have foot or leg rests on her wheelchair and the therapist was not aware until she told her to stop. RN #902 stated the therapist never reported the incident to her. RN #902 reported she assessed Resident #29's foot and found that it was not red or swollen but Resident #29 stated it was slightly painful. RN #902 reported that she provided Resident #29 an as needed Tramadol (narcotic/pain) and informed the night shift nurse of the incident. RN #902 stated she did not notify the family or doctor. RN #902 reported she found the therapist about 10 minutes after she spoke with Resident #29 and the therapist stated that Resident #29's foot got tangled in the wheelchair when she was taking her to therapy in her wheelchair. Telephone interview on 07/05/23 at 12:21 P.M. with OT #700, revealed the incident occurred between 12:30 P.M. and 1:00 P.M. on 06/27/23 and she did not observe Resident #29's leg or foot tangled under her wheelchair because she backed the wheelchair up after she felt resistance and the resident yelled out. OT #700 stated she notified the nurse approximately 30 minutes after the incident and she returned Resident #29 to her room instead of doing therapy with her. Review of the facility's change in condition policy dated February 2021 revealed the facility will notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition. This deficiency represents non-compliance investigated under Complaint Number OH00143879. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 3 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy, review of hospital records, review of facility investigation, review of employee personnel files and staff and resident interview, the facility failed to ensure Resident #29 was provided adequate assistance and the use of required footrests during transport to prevent an avoidable injury. This resulted in Actual harm on 06/27/23 when Occupational Therapist (OT) #700 was transporting the resident in a wheelchair without proper footrests being in place. During the transport, the resident's right leg fell to the ground and went under the wheelchair. The resident complained of pain and was noted to have swelling to the area. An x-ray, obtained on 06/28/23 (a day after the incident) revealed the resident had a closed displaced fracture of the medial malleolus of the right tibia. This affected one resident (#29) of three residents reviewed for accidents. The facility census was 63. Findings include: Review of the medical record for Resident #29's revealed an admission date of 09/30/22. Resident #29 had diagnoses including multiple sclerosis (MS), morbid obesity due to excess calories, difficulty in walking, muscle weakness, and other symbolic dysfunctions. Review of the care plan for Resident #29 dated 10/02/22, revealed the resident had limited physical mobility related to MS and muscle weakness. Interventions included the resident used a wheelchair and was totally dependent on staff for locomotion. Review of a facility document titled Certificate of Medical Necessity dated 10/31/22 for Resident #29, revealed the resident had history of MS, impaired coordination, inability to complete mobility and contracture to right knee with impaired ability to self-propel. The document revealed the resident required a customized wheelchair. Resident #29 required elevated leg rests due to increased edema in the bilateral lower extremity, and she was unable to bend her right knee past 10 degrees due to knee contracture. Therefore, the document indicated the resident must keep her right leg straight at all times and in order to get right leg off the ground, the facility must use an elevated leg rest. The resident's leg had to be off the ground in order for her to be able to self-propel. The resident was ordered an Access Tilt in Space wheelchair through Sunrise medical. The customized wheelchair was equipped with reclining back, elevated leg rests due to resident's 10-degree right knee flexion and a larger back gap. The document was signed by Physician #901. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #29 revealed the resident was cognitively intact. The assessment revealed Resident #29 required total dependence of two (staff) for transfers and extensive assistance of one (staff) for locomotion. Review of the occupational therapy evaluation dated 06/26/23 for Resident #29, revealed the resident was being seen with goals to increase activity tolerance for functional activities of choice, improve ability to wheel at least 50 feet, make two turns once seated in the wheelchair, safely self-propel her wheelchair in her room and to safely negotiate obstacles while self-propelling her wheelchair. Resident #29 was dependent for safely wheeling at least 50 feet and making two turns, required substantial or maximum assistance for self-propelling her wheelchair in her room and negotiating obstacles while self-propelling her wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 4 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 Review of the controlled drug record dated 06/27/23 for Resident #29, revealed the resident was given Tramadol 50 milligrams (mg) one tablet by mouth for pain on 06/27/23 at 6:00 P.M. Level of Harm - Actual harm Residents Affected - Few Review of a progress note dated 06/27/23 at 6:40 P.M. for Resident #29, revealed the resident was being transferred in her wheelchair by the therapist when the resident's right foot got caught under the wheelchair. Resident #29 complained of pain being a five out of ten (zero was no pain and 10 was severe pain) and pain medication (over the counter Tylenol) was administered. The note revealed Resident #29's range of motion was at baseline. Review of an undated Occupational Therapist (OT) #700's witness statement revealed on 06/27/23, OT #700 was pushing Resident #29 down the hall in her wheelchair and Resident #29 was holding her legs up because her legs have trouble bending enough to use the leg rests. While moving down the hallway, Resident #29 dropped her legs without warning and her right leg twisted under the chair. OT #700 immediately backed the chair up and brought her leg in front of her. OT #700 got her footrests and elevated both legs as best she could and returned Resident #29 to her room. OT #700 was delayed in speaking to the nurse immediately about the incident but spoke with her within approximately a half an hour. Review of a progress note dated 06/28/23 at 9:24 A.M. for Resident #29, revealed the facility notified the nurse practitioner (NP) of Resident #29's right foot being swollen and painful post a wheelchair incident on 06/27/23. A new order was obtained for an x-ray. Review of an imaging report dated 06/28/23 for Resident #29, revealed the resident had an acute appearing medial malleoli fracture with soft tissue swelling. Review of a progress note dated 06/29/23 at 8:39 A.M. for Resident #29, revealed the facility notified the NP of the right foot x-ray results and obtained orders for Resident #29 to be treated. Resident #29 was transferred to the hospital for further evaluation and treatment of her right ankle per Resident #29 and her family's request. The NP, Resident #29 and the resident's family were made aware of the new orders, and all were in agreement with plan of care. Review of a progress note dated 06/29/23 at 12:55 P.M. for Resident #29, revealed the wheelchair company was to come in to assess the wheelchair. Review of a progress note dated 06/29/23 at 7:17 P.M. for Resident #29, revealed the resident returned to the facility by stretcher and a fracture was noted to Resident #29's right foot. Oxycodone 5/325 (narcotic /pain) milligrams (mgs) one to two tablets by mouth every six hours as need for five days was ordered and a follow up appointment with the orthopedic surgeon was ordered as soon as possible. Review of a progress note dated 06/29/23 at 12:43 P.M. for Resident #29, revealed the interdisciplinary team (IDT) met regarding the incident. Upon investigation, the IDT found that Resident #29 was being wheeled in a wheelchair by therapist (identified as Occupational Therapist #700) to the therapy room. During wheelchair transportation, Resident #29 said to the therapist that her foot was caught under wheelchair. Resident #29 stated the therapist did not hear her and was still pushing her when resident yelled out that her foot hurt. The therapist then stopped pushing resident. Resident #29's foot was adjusted. The nurse assessed the resident, range of motion was initiated, and a pain assessment performed with a score of a four to five out of ten. Pain medication was given, and ice was offered but Resident #29 declined as she stated she was always cold and cold hurts. Resident #29 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 5 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 put to bed and the foot of bed was elevated. Staff education was provided an x-ray was obtained. Level of Harm - Actual harm Review of the hospital records dated 06/29/23 for Resident #29, revealed the resident presented to the emergency room for evaluation of right leg, ankle, and foot pain. Resident #29 stated that she was wheelchair bound with a history of MS. Resident #29 was doing physical therapy and her foot got caught in the wheelchair and she heard a pop and had pain. Resident #29 had an x-ray of her ankle done on 06/28/23 and it showed a fracture. Resident #29 stated she was having some significant pain. An x-ray was taken and showed a non-displaced or minimally displaced fracture of the medial malleolus of the right ankle. Resident #29 was diagnosed with a closed displaced fracture of the medial malleolus of right tibia. Resident #29 was placed in an ace wrap and an air cast, was given a prescription for Oxycodone for pain control and ordered to schedule an appointment with orthopedic as soon as possible. Residents Affected - Few Review of RN #902's disciplinary notice dated 06/29/23, revealed the nurse failed to follow proper procedures by not notifying the physician of an acute physical change or incident involving a resident and the family was not notified. Review of Registered Nurse (RN) #902's witness statement dated 06/29/23, revealed while RN #902 was doing rounds on 06/27/23, Resident #29 called her into her room and asked her if the therapist told her what happened. RN #902 stated no and Resident #29 proceeded to tell her that while she was being wheeled to therapy in her wheelchair by the therapist, her right foot got caught under the wheelchair and the therapist did not know and kept wheeling. The resident then yelled for the therapist to stop, and the therapist then rolled her back to her room. RN #902 told Resident #29 she did not hear anything from the therapist and that she would reach out. The resident was still sitting in her chair. She raised her foot up and down and flexed back and forth and it was not red or swollen but was tender. RN #902 administered as needed pain medication and Resident #29 refused ice because of her arthritis. RN #902 asked the resident if she felt like she needed an x-ray and the resident stated no. RN #902 told Resident #29 she would get an x-ray if it was still bothersome when she came back to work on 06/28/23. As she went back to the nursing station, she saw the therapist in the hallway asked if she had something to say to her because Resident #29 told her what happened. The therapist stated I'm sorry, I forgot to tell you her foot was caught in her wheel underneath it. I meant to tell you. RN #902 proceeded to chart the situation and she was due back the next day. RN #902 gave report to the night shift nurse and the next morning the unit manager ordered the x-ray. Review of a physician order dated 06/30/23 for Resident #29, revealed the resident had an order to follow up with orthopedics on 07/24/23 at 8:30 A.M. Review of OT #700's verbal warning disciplinary action form dated 06/30/23 revealed OT #700 failed to report the incident with Resident #29 immediately to nursing staff and OT #700 failed to use foot pedals when transporting residents at all times. Interview on 07/03/23 at 10:56 A.M. with OT #700, revealed she was wheeling Resident #29 down the hallway and Resident #29 was holding both of her legs up in the air. OT #700 stated the leg and footrests were not on the wheelchair due to Resident #29's legs not fitting properly on her current leg and footrests. OT #700 stated Resident #29 dropped her legs unexpectedly while she was pushing her down the hall and Resident #29's right leg and foot got caught and twisted in the wheelchair. Interview on 07/03/23 at 11:00 A.M with Therapy Manager #900, revealed Resident #29 had a specialized wheelchair, and she was aware that her legs did not fit on the wheelchair leg and footrests (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 6 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 appropriately prior the incident due to her knee not bending. Therapy Manager #900 stated the wheelchair company was scheduled to come and look at the wheelchair since the incident occurred. Level of Harm - Actual harm Residents Affected - Few Interview on 07/03/23 at 11:29 A.M. with Resident #29, revealed the resident broke her right ankle and stated the therapist was pushing her wheelchair on the way to therapy. Resident #29 reported she had her right leg up on her left leg because the right leg did not work well, and the right leg fell off the left leg and went under the wheelchair. Resident #29 stated she did not have leg and footrests on her wheelchair at the time of the incident because her legs did not stay on them correctly. Resident #29 reported she wanted to use the leg and footrests on her wheelchair. Observation at the same time, revealed Resident #29's customized wheelchair being stored in her room with two leg rests sitting on the wheelchair. Interview on 07/03/23 at 3:48 P.M. with the Director of Nursing (DON), revealed OT #700 was pushing Resident #29 down the hallway on 06/27/23 at an unknown time when the resident stated ouch. The DON reported OT #700 did not hear the resident and Resident #29 yelled out again and OT #700 stopped. The DON stated Resident #29's foot was twisted under the wheelchair. The DON reported OT #700 returned Resident #29 to her room and did not notify the nurse. Resident #29 was talking about the incident to another resident and RN #902 overheard them talking about the incident. The nurse assessed the resident for pain on 06/27/23 and Resident #29 had no initial signs of swelling and was given as needed pain medication. The DON stated RN #902 told Resident #29 that she would contact the doctor the next day if her foot hurt. The DON reported RN #902 did not contact the doctor, family, or management on 06/27/23 regarding the incident which was against the facility's policy. The DON stated management found that RN #902 charted about the 06/27/23 incident on 06/28/23 and the family and physician were contacted based upon that progress note. The DON reported Resident #29 was ordered an x-ray on 06/28/23 and the results came back on 06/29/23 and found Resident #29 had an ankle fracture. Resident #29's family and physician were notified on 06/29/23 and Resident #29 was sent to the hospital for evaluation. The DON stated RN #902 was terminated for failing to notify the physician or family of the incident on 06/27/23 involving Resident #29 and OT #700 was written up for failing to notify the nurse and pushing Resident #29 in a wheelchair without the leg and footrests. The DON reported the facility educated therapy staff on change in condition, but the facility did not educate any other staff on the use of leg and footrests. The DON also stated the facility did not evaluate all resident wheelchairs for leg and footrests or proper functioning. Telephone interview on 07/05/23 at 12:07 P.M. with RN #902, revealed she was doing her rounds on 06/27/23 at around 5:30 P.M. or 6:00 P.M. when Resident #29 told her about the injury. Resident #29 told RN #902 that she was being pushed in a wheelchair by the therapist when her foot went underneath it because she did not have foot or leg rests on her wheelchair and the therapist was not aware until she told her to stop. RN #902 stated the therapist never reported the incident to her. RN #902 reported she assessed Resident #29's foot and found that it was not red or swollen but Resident #29 stated it was slightly painful. RN #902 reported that she provided Resident #29 an as needed Tramadol (narcotic/pain) and informed the night shift nurse of the incident. RN #902 stated she did not notify the family or doctor. RN #902 reported she found the therapist about 10 minutes after she spoke with Resident #29 and the therapist stated that Resident #29's foot got tangled in the wheelchair when she was taking her to therapy in her wheelchair. Telephone interview on 07/05/23 at 12:21 P.M. with OT #700, revealed the incident occurred between 12:30 P.M. and 1:00 P.M. on 06/27/23 and she did not observe Resident #29's leg or foot tangled under her wheelchair because she backed the wheelchair up after she felt resistance and the resident yelled out. OT #700 stated she notified the nurse approximately 30 minutes after the incident and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 7 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 - Actual harm Residents Affected - Few returned Resident #29 to her room instead of doing therapy with her. OT #700 reported she got Resident #29's leg and footrests from her room to transport Resident #29 back to her room, but Resident #29's right leg did not fit on the foot plate properly due to her knee not bending so she propped it up on the foot plate. Review of OT #700's personnel file revealed OT #700 was hired by the therapy company at the facility on 11/08/21 and was educated on accident prevention on 09/20/22. Review of the facilities in service on reporting acute physical and mental changes of incidents dated 06/29/23 revealed therapy staff including OT# 700 were educated on reporting changes. Review of the facility's change in condition policy dated February 2021, revealed the facility will notify the resident, his or her attending physician and the resident representative of changes in the resident's medical condition. This deficiency represents non-compliance investigated under Complaint Number OH00143879. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 8 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and policy review, the facility failed to ensure residents received food that was palatable and appetizing to them and which met their nutritional recommendations. This affected 15 residents (#1, #3, #4, #5, #18, #20, #33, #34, #35, #38, #48, #50, #55, #59, and #60) who received food on the 200-unit. The facility census was 63. Residents Affected - Some Findings include: Review of the resident council meeting minutes dated 05/16/23 revealed residents stated the food was coming out cold. Review of the resident council meeting minutes dated 06/20/23 revealed the temperature of the food was cold. Observation of the facility's kitchen on 07/03/23 at 8:14 A.M. revealed Dietary Staff #05 to be serving resident meal trays from items that were held on top of the stove in the kitchen. Observation of Dietary Staff #05 taking the temperature of the food items revealed the boiled eggs were 95 degrees Fahrenheit, the bacon was 99.5 degrees Fahrenheit, the sausage links were 122.5 degrees Fahrenheit, the mechanical sausage was 110.5 degrees Fahrenheit, and the grits were 107.9 degrees Fahrenheit. Dietary Staff #05 continued to serve the food items that were held in between 41 degrees Fahrenheit and 135 degrees Fahrenheit without taking the temperature of the food items again. Interview at the same time with Dietary Staff #05, verified the temperatures of the food being held. Dietary Staff #05 also verified she continued to serve the food items without taking the temperatures again while they were in the danger zone. Observations on 07/03/23 at 8:42 A.M. revealed a test tray left the kitchen on the 200-unit cart. All resident trays were retrieved from the meal cart on 07/03/23 at 8:56 A.M. The test tray revealed the scrambled eggs were 111 degrees Fahrenheit, the sausage was 103.5 degrees Fahrenheit, and the oatmeal was 107.5 degrees Fahrenheit and food items were cold to taste. Interview with Dietary Staff #13 and interim Dietary Manager #800 at the same time verified the scrambled eggs, sausage and oatmeal were not palatable and were served below the 135 degrees Fahrenheit holding temperature prior to leaving the kitchen. Interview on 07/03/23 at 11:26 A.M. with Resident #04 revealed the food was cold at times. Interview on 07/03/23 at 11:35 A.M. with Resident #38 revealed meals were often served cold. Review of the facility's undated food temperatures policy revealed all hot items must be cooked to the appropriate internal temperatures and be held and served at a temperature of at least 135 degrees Fahrenheit. Hot food items may not fall below 135 degrees Fahrenheit after cooking unless it is an item which is to be rapidly cooled to 41 degrees Fahrenheit and reheated to at least 135 degrees Fahrenheit. Review of the facility's undated dining experience policy revealed the facility will provide nourishing, palatable and attractive meals that meet the daily nutritional needs and are served at a safe and appetizing temperature. This deficiency represents non-compliance investigated under Complaint Number OH00143586. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 9 of 10 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 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 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 observation, interview and review of facility policy, the facility failed to ensure the food thermometer was properly sanitized while obtaining food temperatures. This had the potential to affect 61 of 63 residents of the facility, excluding residents (#06 and #21) who the facility identified as receiving no food by mouth (NPO). The facility census was 63. Findings include: Observation of the facility's kitchen on 07/03/23 at 8:14 A.M. revealed Dietary Staff #05 to be serving resident meal trays from items that were held on top of the stove in the kitchen. Dietary Staff #05 was observed to put the temperature probe in the boiled eggs that were 95 degrees Fahrenheit and then put the temperature probe in the bacon that was 99.5 degrees Fahrenheit without sanitizing the temperature probe. Dietary Staff #05 was then asked if she had any wipes to sanitize her temperature probe and Dietary Staff #05 continued to wipe the temperature probe on a white washcloth that had a brown color on it that was sitting on the kitchen preparation table prior to placing it in the scrambled eggs. The sausage links were 122.5 degrees Fahrenheit, and the mechanical sausage was 110. 5 degrees Fahrenheit which were observed to be mixed in the same container. Interview at the same time with Dietary Staff #05, verified the temperatures of the food being held. Dietary Staff #05 also verified she did not sanitize her temperature probe between the boiled eggs the bacon it. Dietary Staff #05 also verified she wiped the temperature probe on a white washcloth that had a brown color on it that was sitting on the kitchen preparation table prior to placing it in the scrambled eggs. Review of the facility's undated taking accurate temperatures policy revealed thermometers should be sanitized according to the manufacture instructions. In between uses at one meal, an alcohol swab may be used to sanitize the thermometer. This deficiency represents non-compliance investigated under Complaint Number OH00143586. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366427 If continuation sheet Page 10 of 10