Inspection·June 13, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview the facility failed to ensure the ombudsman was notified of a resident's transfer/discharge to the hospital. This affected one (#80) of two residents reviewed for hospitalization. The census was 80. Findings include: Review of the closed medical record revealed Resident #80 was admitted on [DATE] and sent out to the hospital on [DATE]. Review of progress note dated 04/12/19 revealed Resident #80 was checked on at 1:45 P.M. and discovered his respirations were 22, oxygen saturations were 79-80% on 3 liters of oxygen and pulse was reading 130 beats per minute. the resident was transferred to the hospital, but the note was silent for contacting the ombudsman of the transfer/discharge. Interview with Social Worker (SW) #44 on 06/13/19 at 11:37 A.M. verified she couldn't find the information the ombudsman had been notified regarding Resident #80. She stated if the discharge to the hospital happened on the weekend, it would be the responsibility of the nursing staff to send a fax to the ombudsman office and it was hard to keep track of the receipt for the notification. Interview with Director of Nursing (DON) on 06/13/19 at 1:57 P.M. revealed the facility didn't have a policy related to notification of the ombudsman, the regulation would be followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 2 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0679 Provide activities to meet all resident's needs. 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 and resident interviews, and facility policy review, the facility failed to ensure scheduled activities were provided. This affected six (#30, #43, #58, #66, #71 and #72) of 24 residents reviewed for activities. The facility census was 80. Residents Affected - Some Findings include: 1. Medical record review revealed Resident #58 was admitted on [DATE]. Medical diagnoses included Non-Alzheimer's dementia and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was cognitively impaired. Her functional status was limited assistance for bed mobility, transfers, toilet use and was a supervision for eating. Review of Activity Preferences revealed it was very important for the resident to do things with groups of people, keep up with the news, do favorite activities, go outside for fresh air, participate in religious services, listen to music, have books newspapers and magazines to read. Review of care plan dated 03/15/19 revealed Resident #58 was a potential for alteration in activities due to anxiety. She was interested in arts, crafts, being outside, bingo, cards, church, pet visits, socializing, trips, television and movies. Interventions were to invite and encourage family to attend activities, offer schedule of activities for resident to select choices, provide a monthly calendar, and encourage to attend activities, provide assistance with set up as requested and transportation to the activities. An interview with Resident #58 was conducted on 06/10/19 at 10:27 A.M. and even though she was cognitively impaired she stated there wasn't much activities to do in the facility. Observations of Resident #58 on 06/10/19 at 10:30 A.M. she was sitting in the dining room. At 11:08 A.M. she was smoking. At 3:20 P.M. she was in the dining room walking around aimlessly. Subsequent observations on 06/11/19 at 8:21 A.M. she was lying in bed, at 9:31 A.M. she was walking around aimlessly in the dining room, at 4:00 P.M. she was sitting at the dining room table. Observations made on 06/12/19 revealed at 10:23 A.M. she was walking around the dining room without any purpose. There wasn't any observations of staff encouraging residents at the above mentioned times. A family interview conducted on 06/10/19 at 11:29 A.M. revealed when they were in visiting the resident they didn't observe the staff encouraging the resident to activities. 2. Medical record review revealed Resident #66 was admitted on [DATE]. Medical diagnoses included Non-Alzheimer's dementia. Review of admission MDS dated [DATE] revealed he was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfer, eating and toilet use. Review of the Activity Preferences revealed the resident indicated it was very important to do things with groups of people, keep up with the news, do favorite activities, go outside for fresh air, participate in religious services, listen to music, have books newspapers and magazines to read. Review of care plan dated 04/17/19 revealed Resident #66 was a potential for alteration in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 3 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0679 Level of Harm - Minimal harm or potential for actual harm activities due to anxiety. She was interested in arts, crafts, being outside, bingo, cards, church, pet visits, socializing, trips, television and movies. Interventions were to invite and encourage family to attend activities, offer schedule of activities for resident to select choices, provide a monthly calendar, and encourage to attend activities, provide assistance with set up as requested and transportation to the activities. Residents Affected - Some Observation on 06/10/19 at 10:31 A.M. revealed the resident was lying in bed with covers over his head, at 12:28 P.M. the resident was sitting in his wheelchair in the dining room with his head resting in his hand, at 1:50 P.M. he was sitting in the dining room looking at the wall. Subsequent observations conducted on 06/11/19 at 8:25 A.M. revealed he was lying in bed with blanket over his head, at 9:43 A.M. he was getting up out of bed to get a shower, at 4:16 P.M. he was lying in bed and on 06/12/19 at 10:24 A.M. he was lying in bed. At no time during the observations were there activities provided or encouraged for this resident. 3. Medical record review revealed Resident #71 was admitted on [DATE]. Medical diagnoses included Non-Alzheimer's dementia. Review of annual MDS dated [DATE] revealed Resident #71 was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, toilet use and was supervision for eating. Review of the Activity Preferences revealed Resident #71 reported it was very important to do things with groups of people, keep up with the news, do favorite activities, go outside for fresh air, participate in religious services, listen to music, have books newspapers and magazines to read. Review of care plan dated 05/11/19 revealed Resident #71 had a potential for alteration in activities due to anxiety. She was interested in arts and crafts, being outside, bingo, cards, church, pet visits, puzzles, socializing trips, and television. Interventions were to arrange one to one (1:1) contacts with the resident, arrange for the activity aide to visit and encourage the resident to observe the activity. Observations conducted on 06/10/19 at 10:38 A.M. revealed the resident was wandering up and down the hallway, at 12:05 P.M. she was standing at the exit door, at 12:19 P.M. she was sitting in the dining area. On 06/11/19 at 8:31 A.M. she was lying in bed, at 9:44 A.M. she was receiving care from the staff and at 4:17 P.M. she was sitting on the couch in the dining area. At no time, during these observations, were there activities provided or encouraged for this resident nor were 1:1's provided for the resident. 4. Medical record review revealed Resident #72 was 05/13/19. Medical diagnoses included encephalopathy, cerebrovascular attack, anxiety and depression. Review of admission MDS dated [DATE] revealed Resident #72 was cognitively impaired. Functional status was supervision for bed mobility, limited assistance for transfers and toilet use and supervision for eating. Review of the Activity Preferences revealed it was very important to Resident #72 to do things with groups of people, keep up with the news, do favorite activities, go outside for fresh air, participate in religious services, listen to music, have books newspapers and magazines to read. Review of care plan dated 05/22/19 for Resident #72 revealed she had a potential for alteration in activities due to anxiety, cognitive impairment and impaired decision making. She was interested in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 4 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bingo, cards, church, computers, pet visits, puzzles, socializing, trips, television/movies and music. Interventions were to give verbal reminders of activity before commencement of the activity, invite and encourage family to attend, offer schedule of activities for resident to select choices, and invite and encourage to attend daily activity group of interests. Observations conducted of Resident #72 on 06/10/19 at 10:00 A.M. revealed she was in her room, at 2:44 P.M. she was sitting in the dining room. On 06/11/19 she was observed at 8:30 A.M. in the dining room eating breakfast, at 9:40 A.M. she was in and out of her room, at 4:16 P.M. she was in her room, and on 06/12/19 at 10:27 A.M. she was observed sitting at the table in the dining room. At no time during these observations were there activities provided or encouraged for this resident. An interview conducted with Resident #72 on 06/10/19 at 2:44 P.M. revealed even though she was cognitively impaired, she was able to answer questions appropriately. She stated she did not get invited to activities and if she wanted to go, she had to watch the clock and let the staff know she wanted to go. Review of June 2019 calendar for activities revealed on 06/10/19 activities were scheduled at 9:30 A.M. news, 10:30 A.M. crafts, 2:00 P.M. bingo. On 06/11/19 the calendar revealed activities were scheduled at 9:30 A.M. news. None of these activities was observed taking place on the unit on 06/10/19 or 06/11/19 An interview with Activity Director (AD) #33 on 06/11/19 at 11:08 A.M. revealed the activity calendar was the correct one for the memory care unit. She stated if a resident from the memory care unit wanted to go to activities, then they would be taken off the unit to another unit. She revealed she wasn't aware if activities were being provided for the memory care unit on the 300 hall on 06/10/19 or 06/11/19 because it was the responsibility of the activity aide to make sure they were being done. An interview with the Activity Aide (AA) #70 on 06/11/19 at 11:15 A.M. verified there wasn't any activities provided on the memory care unit on 06/10/19 at 9:30 A.M. 10:30 A.M. and 2:00 P.M. and on 06/11/19 at 9:00 A.M. AA #70 also revealed she said she did not encourage the residents to attend the activities on the above dates and times. An interview conducted on 06/11/19 at 3:00 P.M. with State Tested Nursing Aide (STNA) #72 verified there wasn't any activities being provided on 06/10/19 at the above mentioned times. 5. Review Resident #30's medical record revealed an admission date of 03/19/09. Diagnoses included persistent vegetative state, cerebral infarction, hypertension, quadriplegia, bipolar disorder, and post-traumatic stress disorder. Review of a quarterly MDS dated [DATE] indicated cognitive impairment and total dependence on one to two staff for activities of daily living. Review of the care plan dated 01/06/12 revealed activity focus with interventions to engage resident in activities, invite and encourage to attend daily, and transport resident to activities. The care plan documentation indicated Resident #30 could exhibit eye tracking, appropriate facial responses, and positive facial expressions during activities. She would blink once for yes and twice for no. Review of the May and June 2019 activity participation logs for Resident #30 failed to reveal any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 5 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0679 Level of Harm - Minimal harm or potential for actual harm bingo or food activities. The log contained music, reminiscing, public interaction, socialization, two religious activities and some observations. Attempt to interview Resident #30 on 06/10/19 at 9:52 A.M. revealed the resident made direct eye contact and blinked eyes in a slow deliberate manner with facial expressions. Residents Affected - Some Observation of bingo activity at 2-2:10 P.M. on 6/10/19, 6/11/19, 6/12/19 and 6/13/19 failed to reveal Resident #30 in attendance. Phone interview with Resident #30's family member on 06/10/19 at 2:56 P.M. reported she had never seen Resident #30 in an activity, nor had staff questioned her about the resident's preferences. Interview on 06/11/19 at 1:23 P.M. with STNA #86 reported Resident #30 never went to activities since she was physically unable to participate. Observation of Resident #30 on 06/11/19 at 2:09 P.M. revealed the resident was Hoyer lifted to bed by STNAs, on 06/12/19 at 10:10 A.M. the resident was lying in a gerichair (wheeled recliner) in the common area without any interaction from staff, on 06/13/19 the resident was lying in gerichair in the common area from 9:11 A.M. to 10:40 A.M. without any staff interaction. Interview on 06/12/19 at 2:54 P.M. with AD #33 reported Resident #30 attended bingo and food activities. Interview on 06/12/19 at 3:12 P.M. with AA #70 reported she runs the bingo activity and Resident #30 never attends bingo. AA #70 further reported if an activity is on the unit where the resident resides, staff will pull her chair closer so Resident #30 can observe the activity. Review of June 2019 calendar for activities revealed activities were scheduled on 06/10/19 activities at 9:30 A.M. news, 10:30 A.M. crafts, 2:00 P.M. bingo. On 06/11/19 the calendar revealed activities scheduled on 9:30 A.M. news. On 06/12/19 the calendar revealed 9:30 A.M. coffee, 10:30 A.M. crafts, 10:30 A.M. bible study, 2 P.M. bingo, 3:30 P.M. trivia. On 06/13/19 the calendar revealed activities scheduled on 9:30 A.M. coffee, 10:30 A.M. crafts, 2 P.M. bingo, 3:30 P.M. Uno, 6 P.M. movie. 6. Review of Resident #43's medical record reveled an admission date of 10/10/18. Diagnosis included pneumonia, dementia, hypertension, and bradycardia. Review of quarterly MDS dated [DATE] indicated cognitive impairment and extensive assist of one for transfers/toileting/dressing/hygiene, with supervision only for ambulation and eating. Further review of the MDS included a screening for depression with a score of 10 which had increased from a score of five on admission. Review of the care plan dated 10/22/18 revealed activity focus with potential alteration due to anxiety and impaired communication. The care plan documentation indicated interest in being outside, cards, church, pet visits, socializing, trips, television, movies, and music with interventions of - invite and encourage to attend daily. The care plan included a focus of communication with interventions of a communication board, non-verbal gestures, and anticipation of needs. Review of the activity participation logs for May and June 2019 for Resident #43 failed to reveal any outside activities, church, cards, pet visits, food activities or movies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 6 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0679 Level of Harm - Minimal harm or potential for actual harm Observation of Resident #43 on 06/10/19 at 10:15 A.M., and at 12:15 P.M. revealed he was sleeping in a recliner in his room. An attempt to interview Resident #43 on 06/10/19 at 12:50 P.M. revealed resident made eye contact, smiled, nodded head, but did not respond to any questions. Residents Affected - Some Observation of Resident #43 on 06/11/19 at 1:56 P.M. he was sitting in common area in a wheelchair alone, and on 06/12/19 at 10:00 A.M. he was sitting in common area in dining room without any activity. Interview on 06/12/19 at 2:54 P.M. with AD #33 reported Resident #43 comes to bingo and food activities. She was unable to identify Resident #43's activities of interest as listed on the care plan. AD #33 denied any knowledge of Resident #43's depression, nor the intervention of attending activities to aid in depression treatment. Interview on 06/12/19 at 3:12 P.M. with AA #70 reported she runs the bingo activity and Resident #43 never attended bingo but occasional attended coffee. Observation on 06/13/19 form 9:11 A.M. until 10:40 A.M., Resident #43 was siting in a wheelchair in the common area without any staff interaction Interview with Social Service Designee (SSD) #44 on 06/13/19 at 1:08 P.M. verified the increased depression screening score and stated a score of 10 was significant for presence of depression. SSD #44 reported Resident #43 nor his representative could understand or speak English. She stated the intervention for depression was not care planned except for activity participation. She reported the resident sits with a female resident in the common area that looks like his wife, but they do not interact and do not speak the same language. She also reported a female resident on the secured dementia unit speaks the same language as Resident #43 and sometimes staff brings her to him for interaction. SSD #44 acknowledged that interaction was not care planned, nor documented. Review of the policy entitled Activity Program Planning/Scheduling dated 10/18/01 revealed the Activity Department was responsible for planning and scheduling and Activity Program, consisting of stimulating and therapeutic activities, diverse in focus and consistent with resident's wishes and needs. The calendar will be implemented as written. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 7 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of facility policy the facility failed to post no smoking signs were oxygen was in use. This affected two (#42, #70) of four residents with oxygen in use on the facility's Tristate unit. The facility census was 80. Findings include: 1. Review of Resident #42's medical record revealed an admission dated of 03/10/11. Diagnoses included chronic obstructive pulmonary failure, heart failure, chronic kidney disease, and anxiety. Review of Physician orders for June 2018 revealed an order for oxygen per nasal cannula at two liters per minute to maintain a oxygen saturation of 90 percent or greater. A annual Minimum Data Set (MDS) dated [DATE] indicated cognitive impairment and extensive assist of two required for activities of daily living. 2. Review of Resident #70's medical record revealed an admit date of 05/04/17. Diagnoses included chronic obstructive pulmonary disease, hypertension, chronic pain, bipolar disorder, and Parkinson disease. A quarterly MDS assessment dated [DATE] revealed intact cognition and supervision only required for activities of daily living. Review of physician orders for June 2019 revealed an order for oxygen per nasal cannula at two liters per minute dated 01/09/18, Periodic observations on 06/10/19 from 10:00 A.M. through 6:30 P.M. revealed Residents # 42 and #70 using oxygen in their rooms. Further observations revealed the lack of no smoking signs anywhere near their rooms. interview on 06/12/19 at 12:11 P.M. with Unit Manager (UM) #54 verified Residents #42 and #70 did not have no smoking signs posted at their rooms and both residents were using oxygen. Review of facility policy titled Respiratory: Oxygen Administration Equipment/Administration, dated 05/23/02 revealed Oxygen in use signs must be posted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 8 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure that each resident who received psychotropic medications for behavior did not have increases in the amount of the medication without adequate indications for increasing the medications. This involved one resident (#48) of five reviewed for Unnecessary Medications. The facility census was 80. Findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses as listed in her medical record including major depressive disorder, recurrent severe psychotic symptoms, hypertension, atrial fibrillation, Alzheimer's disease, dementia with behavioral disturbance, and vertigo. The facility completed a minimum data set (MDS) assessment of Resident #48's cognitive and physical functional status dated 04/22/19. The assessment identified the resident as having moderate cognitive impairment, having clear speech and comprehension, requiring only supervision for bed mobility and transfer, and able to walk in her room with her walker. The resident was assessed as receiving an anti-psychotic medication daily on a routine basis. A gero-psychiatry consultation dated 04/26/19 for Resident #48 was reviewed. Review of the 04/26/19 consult revealed the psychiatrist documented the following: This resident shows generally stable behaviors but certainly with ongoing symptoms of depression. She is on multiple medications. In terms of addressing the most problematic symptom for her I think that would be adjustment on medication. Therefore her Wellbutrin (anti-depressant) will be increased to a full dosage. Follow up again in the future to see if this is helpful for her. If not we would need to consider changes on the primary antidepressant. Based on the chronic nature of her mood disturbance it may be difficult to alleviate all of her symptoms especially with ongoing progression of organic brain disease with dementia. In the long run, will consider tapering the Seroquel and possibly the addition of Namenda ( a medication for Alzheimer's disease) but in order to keep things simple at this point, only one change at a time. The psychiatrist noted the resident's diagnoses as major depression with psychosis and dementia with behavioral disturbance. Review of Resident #48's current physician orders and medication regimen revealed the resident was receiving 75 milligrams (mg) of an anti-psychotic medication (Seroquel) daily at bedtime. The diagnoses for the use of the medication listed on the physician's order was for dementia and other diseases classified elsewhere with behavioral disturbance. Further review revealed the resident's dose of Seroquel was increased from 50 mg to 75 mg daily on 06/06/19. Review of the resident's nursing progress notes dated 06/03/19 revealed an entry by Registered Nurse (RN) #2. RN #2 documented that Resident #48 was tearful and stating that I'm just depressed, I want to go home and I know that's not going to happen, how would you feel. RN #2 noted that one on one attention and redirection was provided with some effect. She documented that she and the resident began looking at resident's pictures with the resident explaining the picture, and the resident was noted to be less tearful afterwards. RN #2 documented the resident was resting quietly in her room in bed looking at pictures with no signs or symptoms of distress noted. She notified the resident's physician of the increased tearfulness, and no new orders were received. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 9 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm An interview was conducted with Resident #48 on 06/10/19 at 3:43 P.M., and the resident was observed. The resident was alert to herself, and her situation. She reported she did like to stay in her room, but there were activities she could go to but she wasn't' a big activity person. She stated she liked to read books, watch television in her room, and talk on the telephone with her family. The resident was talkative and pleasant at the time of the interview, and talked about a business she and her husband used to run. Residents Affected - Few An interview was conducted with RN #2 on 06/12/19 at 3:38 P.M. regarding Resident #48 and her behaviors and depression. She reported the resident gets severely depressed at times, and will also verbalize she is depressed. RN #2 reported that when this happens the resident will get out her family pictures and she will look through them with her and it makes her feel a little better. She stated the resident was on an anti-psychotic (Seroquel) and had a history of suicidal ideation's but nothing recent. RN #2 reported that the resident's family does visit frequently and take her out. On 06/13/19 at 10:00 A.M. Resident #48's behavior flow record for May and June of 2019 was reviewed with RN #2. RN #2 affirmed there were no documented incidents of the resident having tearfulness on the the May 2019 or June 2019 behavior flow record, but did have some incidents of being withdrawn. She also affirmed there was no documentation of the resident having episodes of tearfulness in the nursing progress notes other than the note she made on 06/03/19. An interview was conducted with nurse manager, RN #63 on 06/13/19 at 9:07 A.M. regarding how and why Resident #48's Seroquel was increased on 06/05/19. She stated she herself faxed Resident #48's psychiatrist regarding an increase in the resident's behaviors and symptoms of depression. The resident's nursing progress notes were reviewed for the past 30 days with RN #63 and she affirmed there was no documentation of the resident having increased tearfulness except for the 06/03/19 entry by RN #2. On 06/13/19 at 9:07 .A.M RN #63 provided documentation of notification of Resident #48's psychiatrist on 06/05/19 of the resident having increased symptoms of depression. She documented on the facsimile that Resident #48 has been complaining of feeling depressed, wanting to go home, and increased tearfulness. The psychiatrist ordered to increase the resident's Seroquel to 75 mg at bedtime. There was no documented evidence to support the resident had any increase in depressed behaviors when the the resident's Seroquel was increased. However, there was documentation to support that non-pharmacological interventions were effective in addressing the resident's symptoms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 10 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of facility policy the facility failed to ensure there was identifiable information in the medical record. This affected one (#71) of three residents reviewed for accidents and one (#18) of four residents reviewed for oxygen use. The census was 80. Findings include: 1. Medical record review revealed Resident #71 was admitted on [DATE]. Medical diagnoses included Non-Alzheimer's dementia. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, toilet use and was supervision for eating. Review of the nurses notes from 04/01/19 through 05/14/19 revealed they were silent to an to the resident's left hand/fingers. Further review of the nurses notes revealed on 05/15/19, Licensed Practical Nurse (LPN) #68 documented discoloration with slight edema continued on the left hand/fingers. An observation on 06/12/19 at 3:00 P.M. revealed Resident #71 was sitting in the dining room and the residents left third finger and pinky had some swelling and slight discoloration. Interview on 06/12/19 at 3:23 P.M. with Licensed Practical Nurse (LPN) #68 revealed he was the nurse who wrote the note on 05/15/19. LPN #68 indicated during report he received information the resident had discoloration and slight edema to the left hand/fingers. He said he didn't think the facility knew where the injury came from. Interview with the Director of Nursing (DON) on 06/12/19 at 3:29 P.M. revealed prior to the note written by LPN #68, LPN #17 had done an incident report for the discoloration of the left hand and fingers. The DON stated when the nurse typed in the top section of the incident report the note would carry over into the progress notes, but since there were updates to the electronic record, it didn't carry over to the progress notes anymore. She said she could read the incident report to the surveyor, but couldn't let the surveyor see it. She said the incident report was done on 05/15/19 at 11:29 A.M. and revealed the physician and the family were notified. She said the resident was noted to have swelling to her third and pinky finger, but was still able to move it without pain. She stated the report said there were no witnesses found and it was determined the resident walked up and down the halls with unsteady gait. The resident bumped into things and was combative with care. There was no intervention put into place. She said there was no noted facial grimacing or complaint of pain when using the hand. When asked if there any interviews attached to the incident report she said no but the report indicated no witnesses found so she thought the nurse interviewed the staff and residents to see what happened. Interview with the Corporate Nurse (CN) #107 on 06/12/19 at 4:30 P.M. revealed the incident report would carry over to the progress notes and there hadn't been any updates to change it. She said it was still functioning that way. 2. Review of Resident #18's medical record revealed an admission date of 02/22/18. Diagnoses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 11 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 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 0842 Level of Harm - Minimal harm or potential for actual harm included chronic obstructive pulmonary disease (COPD), diabetes, anemia, heart failure, kidney disease, major depressive disorder and anxiety. Review of a quarterly MDS assessment dated [DATE] revealed intact cognition, limited assist of one needed for activities of daily living, verbal and physical behaviors toward others, and no rejections of care. Residents Affected - Few Review of the care plan dated 02/22/18 revealed a problem of COPD with interventions that included continuous positive airway pressure (CPAP) at hours of sleep, oxygen continuous per mask, allow rest periods with care, and access oxygen saturations every shift. Review of physician orders for June 2019 revealed orders for continuous oxygen per mask every shift and a CPAP device at hours of sleep. Attempt on 06/10/19 at 10:20 A.M. to interview Resident #18 was unsuccessful due to the resident was having nausea and vomiting Observation on 06/10/19 at 3:41 P.M. revealed Resident #18 lying in bed with oxygen on at two liters per nasal cannula. Interview on 06/12/19 at 12:00 P.M. with MDS nurse #55 reported Resident #18's care plan indicated she was to wear the oxygen mask but the resident had refused to. MDS nurse #55 indicated this was addressed in a separate part of the care plan. MDS nurse #55 also stated the care plan was correct, that Resident #18 had a bilevel positive airway pressure (BIPAP) device (resident actually had a CPAP for hours of sleep. She denied knowledge of oxygen flow. Interview on 06/12/19 at 12:11 P.M. with LPN #54 reported Resident #18 had not worn an oxygen mask in greater than one year. LPN #54 verified Resident #18's oxygen order was incorrect in mechanism of delivery and did not indicate the liter flow, but the CPAP order was correct. Observation on 06/12/19 at 12:19 P.M. revealed Resident #18 sitting in her room in a recliner with oxygen on two liters per nasal cannula. Review of facility policy titled Respiratory: Oxygen Equipment/Administration, dated 05/23/02, indicated an order must detail liter flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 12 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy the facility failed to ensure staff followed a care plan for residents who were in contact isolation. This affected one resident (#72) of one reviewed for isolation. The facility identified only one resident currently on isolation. The facility also failed to ensure the temperature of the water in the washer reached 160 degrees when washing clothes. This had the potential to affect all 80 residents. The census was 80. Residents Affected - Many Findings include: 1. Medical record review for Resident #72 revealed an admission date of 05/13/19. Medical diagnoses included encephalopathy, cerebrovascular attack, anxiety and depression. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively impaired. functional status was supervision for bed mobility, limited assistance for transfers and toilet use and supervision for eating. Review of physician orders dated 06/07/19 revealed contact precautions for Clostridium Difficile (C-diff) infection. Review of the acute care plan for Resident #72 dated 06/07/19 revealed Resident #72 was in contact isolation for the infection C-diff. Interventions included she may come to the dining area, but chair needed to be washed after the resident got up from it. Observation of Resident #72 on 06/10/19 at 12:43 P.M. revealed she got up from the table in the dining room and went to her room. Further observation of the dining room chair revealed staff did not wash the chair after the resident got up from the chair and left the dining room. Interview with State Tested Nursing Aide (STNA) #85 on 06/10/19 at 2:34 P.M. verified she didn't wash the seat Resident #72 was sitting in for lunch. Review of facility policy entitled Clostridium Difficile dated 10/18/01 revealed residents with diarrhea associated C-diff will be placed in contact isolation. Procedures would be to observe proper hand hygiene procedures by washing hands with soap and water, assist or encourage resident to wash their hands as needed, and disinfect shared items which may be fecally contaminated between resident use. 2. Observations of the washing machine in the laundry room on 06/13/19 at 9:00 A.M. revealed no identification on the washing machine to indicate if it was a hot or cold temperature machine. Observations of the temperature of the washing machine with Maintenance Staff (MS) #106 revealed the temperature was 150 degrees. Interview with the HS #60 on 06/13/19 at 9:13 A.M. revealed she didn't know if the washer was a hot or cold temperature machine. Interview with the MS #106 on 06/13/19 at 10:00 A.M. verified the temperature of the washing machine was 150 degrees and he was not aware the temperature should be 160 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 13 of 14 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 365554 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/13/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Glen Meadows 3472 Hamilton Mason Road Hamilton, OH 45011 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review of policy entitled Infection Control--Laundry/Linen dated 05/01/15 revealed linen should either be washed at 160 degrees for a minimum of 25 minutes or 71-77 degrees plus a 125 part-per-million (ppm) chlorine bleach rinse will be used to destroy microorganisms. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 14 of 14