Health inspection·November 16, 2023

F 0550 Resident #44 standing up with gloves on. Level of Harm - Minimal harm or potential for actual harm Interview on 11/13/23 at 11:53 A.M. with STNA #170 confirmed she was standing in the dining room feeding the resident and was wearing gloves to feed her. Interview at the time of observation revealed she shouldn't be feeding the resident this way. Residents Affected - Few Observation on 11/16/22 at 8:22 A.M. revealed agency STNA #171 wearing gloves in the dining room while residents were eating. She opened a carton of orange juice and placed a straw in the carton and placed the straw up to Resident #44's mouth to drink with her gloves on. Interview on 11/16/23 at 8:25 A.M. with STNA #171 confirmed she was wearing gloves in the dining room and confirmed she had gloves on while serving Resident #44 her orange juice, and stated she wasn't supposed to wear gloves in the dining area unless she was touching food. Review of policy entitled Dignity dated 02/01/21 revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are always to be treated with dignity and respect. Staff are always to speak respectfully to residents. Review of policy entitled Using Gloves dated 04/01/13 revealed the staff should wear gloves: 1. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. 2. When the employee's hands have any cuts, scrapes, wounds, chapped skin, or dermatitis. 3. When cleaning up spills or splashes of blood or body fluids. 4. When cleaning potentially contaminated items. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 2 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure advanced directives were consistent within the medical record. This affected one resident (Resident #33) of eight residents reviewed for advanced directives. The facility census was 97. Findings include: Review of Resident #33's medical record revealed an admission date of 02/08/22. Diagnoses included Parkinson's disease, acute and chronic respiratory failure, acute pulmonary edema, heart failure, psychotic disorder with delusions due to known physiological, dementia, anxiety, and major depression disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was mildly cognitively impaired. Review of Resident #33's paper medical record revealed a Do Not Resuscitate (DNR) Order Form dated 02/09/22 revealing the resident's advanced directive was DNR Comfort Care Arrest. Review of the current physician order dated 08/15/22, located in the electronic medical record (EMR), revealed Resident #33's advanced directive was Do Not Resuscitate Comfort Care (DNRCC), meaning providers will conduct an initial assessment, perform basic medical care, clear airway of obstruction or suction, if necessary for comfort or to relieve distress, may administer oxygen, CPAP or BiPAP, if necessary, may obtain access for hydration or pain medication to relieve discomfort, but not to prolong death, if possible, may contact other appropriate health care providers. Interview on 11/13/23 2:19 P.M. with Licensed Practical Nurse (LPN) #158 stated staff members could check either the paper chart or the EMR to determine a resident's advanced directives, if needed. LPN #158 verified Resident #33's advanced directives order in the EMR did not match the order in the paper chart, and stated she would take care of correcting it. Review of facility policy titled, Do Not Resuscitate Order, dated April 2017 revealed documentation of advanced directives will be maintained by the facility in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 3 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, staff interviews, resident interviews, and policy review, the facility failed to ensure residents had a safe, comfortable, and homelike environment. This affected eight (Residents #36, #13, #58, #45, #86, #55, #30, and #78) of eight residents reviewed for environment. Additionally, this affected all residents residing on the Unit B Memory Care Unit (MCU). The census was 97. Findings included: 1. Observation of Resident #36's and Resident #13's room on 11/13/23 at 2:19 P.M. revealed the walls in the room had plaster on them that didn't match the paint, there were scuff marks on the sliding door that went into the bathroom, and the top of the vanity was scarred up and had ink of newspaper imbedded in the top of it. 2. Observation of Resident #58's and Resident #45's room on 11/14/23 at 7:18 A.M. revealed dry wall was missing from the sliding door that went into the bathroom. 3. Observation and interview 11/15/23 at 8:21 A.M. with Resident #86 revealed she was sitting in her room with a jacket on and said it was cold in her room. She stated she told a nurse about the room temperature, but no one came to look at it. Resident #86 said her sliding glass door was cloudy too. A text message was sent to Maintenance Director (MD) #112 by Licensed Practical Nurse (LPN) #4 requesting him to look at the temperature in Resident #86's room. Interview on on 11/15/23 at 1:30 P.M. with MD #112 verified he hasn't checked his text messages, and proceeded to check them and discovered he had one from the nurse about the temperature in Resident #86's room. Observation on 11/16/23 at 8:30 A.M. revealed Resident #86 was in the hall with a jacket on and said no one came to look at her temperature in her room. Observation and interview on 11/16/23 at 9:00 A.M. with MD #112 revealed he looked at the Resident #86's unit in her room yesterday but needed a part to fix it. He checked the temperature in the room of the resident, and it was 69.5 degrees. He got down on his knees and opened the heating and air conditioning unit and said he was able to fix it. Review of policy titled, Quality of Life-Homelike Environment, dated 05/01/17 revealed residents are provided with a safe, clean, comfortable, and homelike environment. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility will also provide comfortable and safe temperatures (71 degrees Fahrenheit (F) - 81 F). 4. Observations of Unit B Memory Care Unit (MCU) on 11/15/23 at 8:30 A.M. revealed a ceiling tile sticking up into the ceiling. Additionally, the door going off the front hall revealed the paint was scraped off the door. The sitting room had scratches and paint that were scrapped off the walls. The halls going down the B unit had paint coming off them and walls were all scuffed up. There was paint off the doorway going into the dining room. Lastly, there were drawers in the dining area with the molding around the drawers with paint gouged off them. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 4 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Observation on 11/13/23 at 11:16 A.M. of Unit B Memory Care dining room revealed food stains and dried food on the interior wall measuring one foot by two foot. Over the entire wall surface, measuring 8 foot by six foot, the wall paint was discolored with splotchy areas of red and turquoise areas. Surrounding walls were gray blue with no splotchy areas. Interview on 11/13/23 at 11:16 A.M. the Unit Manager #75 verified the wall was spoiled with dried food and was discolored due to improper use of a chemical cleaner. Observation on 11/13/23 11:19 A.M. revealed Housekeeper #81 attempting to clean dried food on the interior wall of the dining room. The chemical cleaner made splotchy areas and turned the wall a turquoise color as it was cleaned. Interview with Housekeeper #81 verified the wall was being discolored by the cleaner she was using, which included bleach. She stated the wall should have been a blue gray, like the remaining walls in the dining room. Housekeeper #81 verified the wall had dried food and it did not appear homelike with the discolored wall. Interview on 11/13/23 at 11:28 A.M. with Housekeeping Supervisor #76 verified the wall was discolored due to incorrect cleaner being used and the wall should be repainted. 6. Record review of Resident #55 revealed the resident was admitted to the facility on [DATE] . Diagnoses for Resident #55 included Alzheimer Disease, restlessness and agitation, and psychotic disturbance. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assistance with bed mobility and transfers. Observation on 11/15/23 at 10:17 A.M. revealed Resident #55's bed's headboard was loose, and on the left side, was not attached to the bed. Resident #55's wheelchair armrests, left and right sides, were cracked with jagged edges exposing a non-cleanable material. Interview on 11/15/23 at 10:18 A.M. with State Tested Nurse Aide, (STNA) #52 verified the bed's headboard was not attached to the bed on the left side. She stated the headboard appeared to be missing a screw and stated she did not know how long it had been unattached from Resident #55's bed. STNA #52 also verified both wheelchair armrests were split open exposing non cleanable material. STNA stated Resident #55's skin was fragile skin and the armrests were often soiled during meals. 7. Record review of Resident #30 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #30 included malignant neoplasm of the skin infections of the central nervous system and dementia. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had severely impaired cognition and required extensive assistance for bed mobility. Observation on 11/15/23 at 10:03 A.M. revealed Resident #30 had a bed mattress with no linen. The mattress had a split along the left outer edge, from the top of the mattress to the middle length of the mattress, about four foot long and the eight inches width of the mattress. The split mattress protective layer exposed the inner foam of the mattress. Interview on 11/15/23 at 10:10 A.M. with State Tested Nurse Aide (STNA) #52 verified the mattress was split and the inner foam was exposed. STNA #52 stated the resident grabs the side of the mattress when moving in bed and was unsure how long the mattress had been split open. STNA #52 verified the resident was incontinent and the mattress foam could become soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 5 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 8. Review of the medical record for Resident #78 revealed an admission date of 03/17/23. Diagnoses included delusional disorders, chronic viral hepatitis C, depression, type 2 diabetes mellitus with hyperglycemia, opioid abuse, other stimulant abuse, vascular dementia moderate with agitation. Review of the MDS assessment dated [DATE] revealed Resident #78 had a Brief Interview of Mental Status score of 15, indicating the resident was cognitively intact. Resident #78 required staff assistance with completion of Activities of Daily Living (ADLs). Resident #78 was occasionally incontinent of bladder. Observation on 11/13/23 at 10:17 A.M. with Resident #78 revealed thick dust present on the television, dresser and bedside table. Resident #78's room smelled of urine and the bed was noticeably wet with yellow color noted. Observation on 11/14/23 at 8:40 A.M. with Resident #78 revealed thick dust continued to be present on the television and dresser. Interview with Resident #78 revealed she has concerns with housekeeping and thinks they have been on strike for a couple weeks. Resident #78's room smelled of strong urine odor. Interview on 11/14/23 at 8:43 A.M. with the Administrator verified Resident #78's television and dresser had thick dust built up and the room smelled of strong urine odor. Review of the Two-Week Employee Schedule for Housekeeping revealed all rooms are scheduled to be cleaned thirteen out of fourteen days. Review of facility Bedroom Policy Statement dated May 2017 revealed all residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 6 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident received regular care conferences. This affected one (Resident#29) of one reviewed for care conferences. The census was 97. Findings include: Review of Resident #29's medical record revealed an admission date of 12/26/22. Diagnoses listed included prostate cancer, spinal stenosis, major depressive disorder, hypertension, and Parkinson's disease. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was cognitively intact and required extensive assistance with activities of daily living (ADLs). Further review of MDS information revealed quarterly assessments were completed on 04/04/23, 07/04/23, and 09/07/23. Review of social service progress notes revealed a care conference was last held for Resident #29 on 03/16/23. During an interview on 11/15/23 at 10:28 A.M. the Administrator confirmed a care conference was not held for Resident #29 since March 03/16/23. The Administrator confirmed care conferences should be held at least quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 7 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, observation, staff interview, and policy review, the facility failed to ensure a resident's feet were kept clean. This affected one (Resident #47) of four residents reviewed for activities of daily living assistance. The census was 97. Residents Affected - Few Findings included: Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation of Resident #47's feet on 11/13/23 at 10:04 A.M. revealed they were covered with a dark brown substance on the bottom of them. At 10:32 A.M. the Licensed Practical Nurse Unit Manager (UM) #75 came into the room and placed non-skid socks on the residents over the dirty feet. Observation on 11/14/23 at 11:43 A.M. revealed State Tested Nursing Aide (STNA) #168 was providing care for the resident and the bottom of the resident's feet had a black substance on the bottom of her feet. Interview with agency State Tested Nursing Aide (STNA) #168 on 11/14/23 at 11:49 A.M. revealed the STNA noticed the bottom of Resident #47's feet were dirty and confirmed she didn't wash them and placed the non-skid socks on them anyway. Review of the policy entitled, Shower/Bed Bath, dated 10/01/10 revealed the purposes of this procedure was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 8 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide incontinence care per standards of care. This affected one (Resident #47) of one resident observed for incontinence care. The facility census was 97. Findings include: Medical record review for Resident #47 revealed an admission date of 09/15/18. Medical diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired. Her functional status was supervision for eating, substantial/maximal for toileting, supervision for transfers, and partial/moderate assistance for bed mobility. She was always incontinent for bladder and frequently incontinent for bowels. Observation of incontinence care for Resident #47 on 11/14/23 at 11:43 A.M. revealed STNA #168 removed a soiled brief from the resident, stood her up on her walker, and took a wet towel and bent the resident over and wiped her from the front to the back, and then took a dry towel and dried the resident from front to back. STNA #168 did not clean the labia and she did not wash the peri area on the front of the resident. Interview with STNA #168 on 11/14/23 at 11:49 A.M. confirmed she did not clean Resident #47's labia or peri area. Review of the facility policy titled, Perineal Care, dated 10/01/10 revealed for a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (4) Gently dry perineum. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 9 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0690 the buttocks. Do not reuse the same washcloth or water to clean the labia. 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: 365375 If continuation sheet Page 10 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to administer parenteral fluids per professional standards when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications to residents. This affected three (Resident #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the unlicensed company. The facility census was 97. Residents Affected - Some Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 11 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 12 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and review of pharmacy board website, the facility failed to provide pharmaceuticals services that assure the accurate acquiring, receiving, and dispensing of drugs when they allowed a company who was not licensed in Ohio by the State Pharmacy Board to administer dangerous intravenous fluid medications. This affected three (Residents #47, #78, and #87) of three reviewed for pharmacy services. The facility identified 22 (Residents #1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 13 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 14 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 interviews, resident interview, and review of facility policy, the facility failed to complete a urinalysis as ordered. This affected one (Resident #78) of one resident reviewed for laboratory services. The facility census was 97. Residents Affected - Few Findings include: Review of medical record for Resident #78 revealed an admission date of 03/17/23. Diagnoses included delusional disorders, chronic viral hepatitis C, depression, type 2 diabetes mellitus with hyperglycemia, opioid abuse, other stimulant abuse, vascular dementia moderate with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had a Brief Interview of Mental Status score of 15, indicating no cognitive impairment. Resident #78 required staff assistance to complete Activities of Daily Living (ADL) tasks. Resident #78 was occasionally incontinent of bladder. Review of nurse's notes for Resident #78 dated 10/18/23 at 4:18 P.M. revealed the resident was noted with increased behaviors as well as reports dysuria (painful urination). Urine was with foul odor. The physician was notified and a new order for urinalysis and culture and sensitivity was received. Review of physician orders revealed an order dated 10/18/23 for a urinalysis and culture and sensitivity. Review of nurse's notes for Resident #78 dated 10/19/23 at 5:57 A.M. revealed the resident was encouraged to void in the bathroom in order to obtain urine for the urinalysis. Resident #78 was noted to be incontinent throughout the shift and changed her pull ups. Review of nurse's notes for Resident #78 dated 10/20/23 at 12:37 A.M. revealed the resident voided in a collection hat earlier in the shift but the specimen was contaminated with feces. Further review of the nurses' notes revealed no documentation the resident's urine was collected for the urinalysis or a urinalysis was completed, and no documentation showing the physician was notified of staff being unable to obtain urine. Further review of the medical record revealed no orders for straight catherization. Interview on 11/15/23 at 8:49 A.M. with Licensed Practical Nurse (LPN) Unit Manager #87 revealed she thought the physician was notified, along with family, that the facility was unable to obtain urine for Resident #78, and that the physician ordered a straight catheterization but the resident refused. LPN Unit Manager #87 verified there was not an order for the straight catheterization. LPN Unit Manager #87 also verified there was no documentation showing the physician was notified of urinalysis not being completed. Interview on 11/15/23 at 4:29 P.M. with Resident #78 revealed she did not refuse catheterization for a urine sample last month, and that it was never offered. Further interview revealed a urine sample was collected yesterday, 11/14/23, via catheterization. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 15 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 11/16/23 at 8:26 A.M. with the Director of Nursing verified the urinalysis was not collected and there was no documentation related to physician notification of the urinalysis not being completed. Review of the Urinary Tract Infections/Bacteriuria - Clinical Protocol dated June 2014 revealed as part of the initial assessment, the physician will help identify individuals who have a history of symptomatic urinary tract infection, and those who have risk factors for urinary tract infections. The physician will order appropriate treatment for verified or suspected urinary tract infections based on a pertinent assessment. Event ID: Facility ID: 365375 If continuation sheet Page 16 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on employee file review and staff interviews, the facility failed to ensure they employed a qualified dietary manager. This had the potential to affect all 96 residents who received food from the kitchen. The facility census was 97. Findings include: Review of Dietary Manager (DM) #105's employee file revealed DM #105 was hired on 04/07/23 and was not a certified diet manager or food service director in the state. The Director of Food Service Job Description, signed by the Diet Manger #105 and the Administrator on 04/07/23, revealed the diet manager must be a food service director in the state. Interview on 11/14/23 at 3:08 P.M. Dietary Manager #105 revealed the registered dietitian was part time, a diet technician visits two times a week, and there was no certified dietary manager at the facility. DM #105 verified she was not a certified dietary manager, had not enrolled in a certified dietary manager course or food service director program from the state. DM #105 stated she had no dietary manager orientation training. Interview on 11/14/23 at 3:08 P.M. with the Administrator verified the facility did not have a qualified certified dietary manager or full time registered dietitian. The Administrator verified the current dietary manager was not enrolled in a certified dietary manager course or food service director program from the state. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 17 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation, and staff interview, the facility failed to provide puree foods per the spreadsheet approved by the dietitian. This had the potential to affect six (Residents #52, #30, #13, #4, #45 and #55) who received puree consistency diets from the kitchen. The facility census was 97. Findings include: Medical record review for Residents #52, #30, #13, #4, #45, and #55 revealed all residents were ordered to receive puree diets. Review of the dinner menu spreadsheet dated 11/14/23 revealed the puree consistency diet was to be prepared with puree carrots and the carrots and the bread was to be pureed separately. The puree carrot portion was four ounces and the puree bread was two ounces. Observation on 11/14/23 at 2:56 P.M. revealed [NAME] #107 prepared puree corn and puree bread together for the vegetable puree. The puree bread was not separated from the puree corn. [NAME] #107 prepared corn, and not carrots as listed on the spreadsheet. The menu spreadsheet and recipe were not used by [NAME] #107. Interview on 11/14/23 at 2:56 P.M. [NAME] #107 verified he had not prepared carrots as listed on the spreadsheet for the puree vegetable, and he pureed the vegetable and bread together. [NAME] #107 verified he used a total of four ounces for the portion of vegetable and bread instead of four ounces of vegetables and two ounces of bread in a separate serving. [NAME] #107 stated he did not follow the spreadsheet or recipes as he had prepared puree foods for a long period of time. Interview on 11/14/23 at 3:08 P.M. with Diet Manager #105 revealed she did not know carrots were to be substituted for corn, and the puree bread was to be prepared separately, according to the menu spreadsheet. She stated [NAME] #107 had been employed so long, he did not follow the spreadsheets for every meal. DM #105 verified the four-ounce portion of combined puree vegetable and bread was underserved by two ounces for the puree consistency diet. Review of policy titled, Kitchen Weights and Measures, dated April 2007, revealed the Food Service Supervisor will train staff in proper use of cooking and serving measurements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 18 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of a facility policy, the facility failed to store food, drink, and meal services items in a safe and sanitary manner. This had the potential to affect all 96 residents who Residents Affected - Many received food from the kitchen. The facility identified one (#1) resident who had orders for nothing by mouth. The facility census was 97. Findings Include: 1. Observation of the kitchen during tour on 11/13/23 from 8:45 A.M. to 9:05 A.M. revealed an unlabeled and undated three gallon pitcher of liquid, a container of sauerkraut dated 11/09/23, and an open container of whole milk with no date in the reach-in refrigerator; an open container of grape jelly with no open date and six bags of rolls with no open or expiration date on the food preparation counter; no thermometer inside the milk cooler; no thermometer in the ice cream freezer and no documentation ice cream freezer temperatures from October and November 2023; there were open containers and bags of french fried onions and pasta with no open dates, boxes of cream of wheat, oats, and rice with no received dates, and a container of coleslaw mix with an expiration date of June 2023 in the dry storage and preparation area; and there were open containers of oats, sugar, and macaroni with no open dates on a shelf under the food preparation table, and insulated lids for resident meal plates stored upright with water collected inside in the main kitchen area. Interview on 11/13/23 at approximately 9:10 A.M with Dietary Manager (DM) #105 verified foods should be labeled and dated with received and open dates, thermometers should be in refrigerators and freezers, expired foods should be discarded, and meal tray lids should be stored to ensure water was drained prior to covering resident meal trays. DM #105 confirmed the findings in the kitchen tour at that time. 2. Observation on 11/14/23 at 7:15 A.M. of the Unit B nursing station resident refrigerator, revealed four bowls of unlabeled and undated food and two open and undated containers of juice. Additional observation of the Unit B nursing station revealed the inside lower surface of the microwave was covered with a brown thick substance. Interview on 11/15/23 at 7:15 A.M. with State Tested Nurse Aide (STNA) #52 verified the food and drink in the resident refrigerator was not labeled or dated, and verified the microwave needed to be cleaned. 3. Observation on 11/15/23 at 7:32 A.M. of the Unit A nursing station resident refrigerator revealed a sign on the refrigerator indicating the refrigerator was only to be used for resident food storage. Further observation revealed two open juice containers with no open dates and a clear bag containing nursing supplies. Interview on 11/15/23 at 7:32 A.M. with Licensed Practical Nurse (LPN) #21 verified all foods should be labeled and dated, and the nursing supplies should not be stored in the resident refrigerator. 4. Observation on 11/15/23 at 7:38 A.M. of the Unit C nursing station resident refrigerator revealed two large brown bags containing food which were unlabeled and undated, and a frozen milkshake with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 19 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0812 no date. Level of Harm - Minimal harm or potential for actual harm Interview on 11/15/23 at 7:382 A.M. with Registered Nurse (RN) #88 verified all items in the resident refrigerator must be labeled and dated. Residents Affected - Many Review of the facility policy titled, Food Receiving and Storage, dated October 2017, revealed all packaged foods stored in refrigerators will be covered, labeled, and dated with a use by date, and items will be properly sealed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 20 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and pharmacy board website review, the facility failed to ensure an outside Intravenous (IV) company (IV Company #700) had a proper license to provide services to residents. This affected three (Residents #47, #78, and #87) of three reviewed for medications administered by IV Company #700. The facility identified 22 Residents (#1, #3, #6, #11, #20, #23, #28, #35, #40, #46, #47, #52, #78, #85, #87, #92, #355, #356, #357, #358, #359, and #360) who received intravenous fluids through the company. The facility census was 97. Findings include: 1. Record review of Resident #87 revealed an admission date of 07/26/23. Diagnoses included pressure ulcer, insomnia, anxiety disorder, major depressive disorder, and unspecified psychosis. Review of the 08/02/23 admission Minimum Data Set (MDS) assessment revealed Resident #87 was cognitively intact and required assistance with Activities of Daily Living (ADLs). Review of Resident #87's physician orders revealed an order dated 08/21/23 for IV Company #700 hydration therapy for nutrition infusion 500 milliliters (ml) per hour per peripheral intravenous (IV) line. 2. Medical record review for Resident #47 revealed an admission date of 09/15/18. Diagnoses included coronary artery disease, diabetes, renal failure, Alzheimer's disease and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Review of Resident #47's physician orders revealed an order dated 06/13/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for functional/cognitive infusion 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for cognitive decline infusion 500 ml per hour per peripheral intravenous (IV) line. 3. Record review of Resident #78 revealed and admission date of 03/08/22. Diagnoses included frontotemporal neurocognitive disorder, essential hypertension, type two diabetes mellitus without complications, morbid obesity due to excess calories, chronic systolic congestive heart failure, major depressive disorder, anxiety, chronic obstructive pulmonary disease. Review of the 10/20/23 quarterly Minimum Data Set (MDS) assessment revealed Resident #78 was cognitively intact. Review of Resident #78's physician orders revealed an order dated 04/25/23 for IV Company #700 micronutrient hydration therapy for nutrition infusion 250 mls at 100 ml per hour per peripheral intravenous (IV) line on 04/27/23. Flush per protocol. An order dated 05/30/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 mls at 250 ml per hour per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 21 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some peripheral intravenous (IV) line. An order dated 07/24/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. An order dated 08/21/23 for IV Company #700 micronutrient hydration therapy for acute chronic wounds Derma infusion 500 ml at 250 ml per hour per peripheral intravenous (IV) line. Review of the Ohio State Pharmacy Board website on 11/15/23 revealed IV Company #700 company did not have a valid license to dispense dangerous drugs in Ohio. Interview with Regional Nurse #300 on 11/15/23 at 8:50 AM. revealed she found out from corporate they were going to try this IV program to enhance quality of life for residents with weight loss, wounds, or hydration issues. There was different types of nutritional IV bags for skin and hydration, and the facility nurses got with facility physicians, who wrote an order for IV Company #700 services. Informed consent and assessments were completed. IV Company #700's nurse would come in and administer the IV fluids, which consisted of vitamins, supplements, and hydration. The last infusion month was August and Regional Nurse #300 was unsure why corporate stopped services, and reported services was on a trial basis and there was a cost per bag. IV Company #700's nurse brought all supplies, ran the IV sessions, and took all supplies when they left. Interview with Regional Nurse #300 on 11/16/23 at 1:40 P.M. verified IV Company #700 did not have a Ohio State Pharmacy Board license to dispense dangerous drugs in Ohio and the facility was unaware of that at the time of IV administrations from April 2023 to August 2023. Phone interview with Ohio State Pharmacy Board Worker #305 on 11/16/23 at 9:38 A.M. revealed IV Company #700 was not licensed in Ohio to dispense dangerous medications such as intravenous (IV) fluids. This deficiency represents non-compliance investigated under Master Complaint Number OH00148169. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 22 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on review of the facility's infection control log, staff interview, and review of facility policy, the facility failed to have an affective antibiotic stewardship program. This affected five (#2, #23, #41, #61, and #91) of five residents reviewed on the infection log. The census was 97. Residents Affected - Some Findings include: Review of the facility's infection log for October 2023 revealed Resident #2, Resident #23, Resident #41, Resident #61, and Resident #91 were ordered and received antibiotic medications for suspected urinary tract infections (UTIs). On 10/01/23, Resident #61 had increased confusion with no elevated temperature and was started on an antibiotic. Resident #61 was noted to have a UTI without a urinary catheter. On 10/04/23, Resident #91 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and was started on an antibiotic. On 10/06/23, Resident #2 was admitted to the facility with a UTI without a urinary catheter, no elevated temperature, and started on an antibiotic. On 10/17/23, Resident #23 had no elevated temperature, but was determined to have a UTI with a urinary catheter in place, and started on an antibiotic. On 10/21/31, Resident #41 displayed increased confusion with no elevated temperature, was found to have a UTI without a urinary catheter, and was started on an antibiotic. Further review of the infection control log revealed the antibiotics were continued when it was determined the five (#2, #23, #41, #61, and #91) identified residents suspected with UTIs did not meet McGeer's criteria (resource for infection surveillance standards). During an interview on 11/16/23 at 10:13 A.M., Registered Nurse (RN) #88, the facility's infection control designee, stated that a resident's physician was not called when a suspected UTI did not meet McGeer's criteria to justify the continued use of an antibiotic. RN #88 confirmed the physician was not notified when the five (#2, #23, #41, #61, and #91) identified residents with suspected UTIs did not meet McGeer's criteria and the antibiotics were continued. Review of the facility policy titled, Antibiotic Stewardship, revised December 2016, revealed the purpose of the program was to monitor the use of antibiotics in residents. When a culture and sensitivity is ordered laboratory results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of a facility document titled, McGeer's Definitions for Healthcare Associated Infections for Surveillance for Long Term Care Facilities, approved on 06/15/12, revealed urinary tract infections includes only symptomatic urinary tract infections. Surveillance for asymptomatic bacteria in the urine absent of new signs and symptoms of a urinary tract infection is not recommended, and represents baseline status for many residents. For symptomatic urinary tract infections, one of the following criteria must be met: The resident does not have an indwelling urinary catheter and has at least three of the following symptoms: Fever (greater than or equal to 38 degrees Celsius (C) or 100.4 degrees Fahrenheit (F) or chills; new or increased burning or pain on urination, frequency, or urgency; may be new or increased incontinence; new flank or suprapubic pain or tenderness; change of character of urine; or worsening of mental or functional status. If the resident has a urinary catheter and at least two of the following signs or symptoms criteria is met. Signs and symptoms include: Fever or chills; new flank or suprapubic pain or tenderness; change in character of urine; or worsening of mental or functional status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 23 of 24 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 365375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 8211 Weller 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)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and review of facility policy, the facility failed to ensure call lights located in resident bathrooms had pull cords and residents would be able to activate if on the floor. This affected four (#29, #31, #89, and #407) of four residents reviewed for call light functionality. The census was 97. Residents Affected - Some Findings include: Observation of four (#29, #31, #89, and #407) resident's bathrooms on 11/14/23 from 3:40 P.M. to 3:45 P.M. revealed the bathroom call lights did not have pull cords to activate the lights. During an interview on 11/14/23 at 3:50 P.M., the Director of Nursing (DON) confirmed Resident #29, Resident #31, Resident #89, and Resident #407's bathroom call lights did not have pull cords. The DON confirmed the four identified residents would not be able to activate the call light if the resident was on the floor in the bathroom. The DON also confirmed the four identified residents were capable of independently activating a call light. Review of the facility policy titled, Answering the Call Light, dated 01/12/20, revealed staff should be sure that a call light is plugged in and functioning at all times. Staff should report all defective call lights to the nurse supervisor promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365375 If continuation sheet Page 24 of 24