Inspection·June 20, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to keep a resident's room clean and sanitary. This affected one (Resident #12) of three residents reviewed for environment. The facility census was 57. Findings include: Review of the medical record for Resident #12 revealed an admission date 03/21/24. Diagnosis included anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Interview on 06/20/24 at 10:35 A.M. with Resident #12 stated the housekeeping staff does not wipe down the furniture in her room. Resident #12 stated they do not sweep under her bed, or corners in the room. Resident #12 stated she took out her own trash from her room because it does not get taken care of. Resident #12 stated her toilet was disgusting, dirty, smells, and had urine ring around the toilet. Observation on 06/20/24 at 10:40 A.M. with Resident #12's room revealed all three of her bedroom walls, and around her air conditioner wall unit was dirty with an unknown black substance, dirt, food particles, and hair balls. Resident #12's bathroom floor was dirty with dirt particles and unknown particles on the floor. Resident #12 had a urine ring around her toilet base. The bathroom trash can had dirt and spots under and around the trash can. Resident #12's floor had scattered unknown black spots on her floor. Observations on 06/20/24 from 11:58 A.M. through 12:10 P.M. with Housekeeping Aide (HKA) #289 revealed she was cleaning Resident #12's room with blinds closed and lights out. HKA #289 opened the blinds at the window and cleaned Resident #12's end table around personal items, and half the bedside table which was part with no personal items. At 12:09 P.M., HKA #289 stated she was almost done cleaning Resident #12's room. Interview on 06/20/24 at 12:09 P.M. with HKA #289 verified she was mopping Resident #12's room a second time. HKA #289 verified she only mopped the main areas and pathways to the room. HKA #289 stated she did not mop under the walker, trash can, or bed. HKA #289 stated she did miss the areas that had dirt and food particles that were against the walls, under the bed, around the air conditioner wall unit, around the end table, around at the bedside table, or in the bathroom. HKA #289 confirmed there was dirt pile (in a pile of dirt that was approximately six inch in diameter in room when sweeping). HKA #289 also confirmed the hairball, urine ring around the toilet, and dirt and spots in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365327 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 365327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Care Center 7777 Cooper Road Cincinnati, OH 45242 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)