Inspection·September 22, 2021

F 0580 change of condition and the physician should have been notified on 07/06/21. Level of Harm - Minimal harm or potential for actual harm Review of policy titled Change of Condition, revised 04/13/13, revealed a change of condition was defined as deterioration in the health, mental or psychosocial status of the resident related to life threatening condition, a significant alteration in treatment or a significant change in the residents clinical condition or status. Life threatening conditions may include respiratory changes. The unit charge nurse or unit supervisor will notify the physician of all changes. Residents Affected - Few 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 09/22/2021 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review and self reported incident (SRI) review, the facility failed to maintain investigation documentation of abuse and neglect allegations to ensure a thorough investigation was completed. This affected seven (Residents #15, #32, #38, #54, #64, #268, # 271) of seven residents reviewed for SRI reporting during the survey. The facility census was 68. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #268 revealed he was admitted to the facility on [DATE]. Review of the medical record for Resident #271 revealed he was admitted to the facility on [DATE]. Review of the facility SRI, dated 11/23/20, revealed the facility reported physical abuse for a resident to resident altercation. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. 2. Review of medical record review for Resident #32 revealed resident was admitted to the facility on [DATE]. Review of the medical record review for Resident #38 revealed an admission date of 04/18/19. Review of the SRI dated 01/23/21, revealed the facility reported a resident-to-resident altercation resulting in emotional abuse. physical abuse for a resident to resident altercation. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. 3. Review of the medical record review for Resident #38 revealed an admission date of 04/18/19. Review of medical record review for Resident #64 revealed an admission date of 08/20/20. Review of the SRI, dated 08/12/21, revealed the facility reported a resident-to-resident altercation resulting in emotional abuse. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. 4. Review of the medical record review for Resident #54 revealed an admission date of 02/22/21. Review of the SRI, dated 09/13/21, revealed the facility reported an allegation of abuse regarding Resident #54 and an employee at the facility. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. 5. Review of the medical record review for Resident #25 revealed an admission date of 08/24/21. Review of the SRI, dated 09/09/21, revealed the facility reported an allegation of neglect regarding Resident #25 and an employee. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. (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 09/22/2021 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 0610 Level of Harm - Minimal harm or potential for actual harm 6. Review of the medical record review for Resident #32 revealed resident was admitted to the facility on [DATE]. Review of the medical record review for Resident #15 revealed resident was admitted to the facility on [DATE]. Residents Affected - Some Review of the SRI, dated 09/07/21, revealed the facility completed an investigation regarding sexual abuse allegation. Review of the facility's investigation revealed no documented statements from any staff members or residents from the date of the event. Interview with the Director of Nursing (DON) on 09/16/21 at 2:42 P.M. confirmed the facility does not have statements from the employee witnesses or resident statements of events. The DON stated she completes the SRI investigations. The DON stated she will interview the staff and residents and summarize their statements. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, dated 11/21/16, stated the facility will have evidence that all alleged violations will be thoroughly investigated. 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 09/22/2021 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 record review, observation, interview and policy review, the facility failed to ensure activities were provided to residents. This affected five (Residents #13, #66, #24, #6 and #50) of 24 residents reviewed for activities. The census was 68. Residents Affected - Some Findings include: 1. Medical record review for Resident #66 revealed an admission date of 09/04/19. Diagnoses included psychosis, and non-Alzheimer's dementia. She was moderately cognitively impaired. Review of the care plan for Resident #66, dated 09/12/21, revealed she was a sociable person and liked to participate in various activities. The following activities were important to the resident: arts and crafts, cards, gardening, music, reading, religious activities, spending time outside, and watching television, and movies. Review of activity calendar dated 09/13/21 revealed crafts at 10:15 A.M., trivia at 12:30 P.M. and music at 4:30 P.M. music. During interview with Resident #66 on 09/13/21 at 10:38 A.M. she stated there weren't many activities. 2. Medical record review for Resident #13 revealed an admission date of 06/01/18. Medical diagnoses included Parkinson's disease, cerebrovascular accident and non-Alzheimer's disease. She was cognitively intact. Review of the care plan for Resident #13, dated 09/15/21, revealed she had potential for alteration in activities anxiety, cognitive impairment, and impaired decision making. The resident was interested in: arts and crafts, being outside, bingo, cards, church, pet visits, socializing, trips, and television, movies, and music. Interventions were to engage resident in group activities and give resident verbal reminders of activities before commencement. During interview on 09/13/21 at 10:32 A.M., the resident stated the facility didn't really have activities. 3. Medical record review for Resident #6 revealed an admission date of 02/26/21. Medical diagnoses included coronary artery disease, heart failure, and diabetes. She was cognitively intact. Review of the care plan for Resident #6, dated 03/04/21, revealed she was a sociable person and liked to participate in various activities. The following activities are important to the resident: bingo, cards, computer activities, gardening, music, reading, religious cavities, spending time outside, watching television, and movies. Give resident verbal reminders of activity before commencement of activity. During interview on 09/13/21 at 10:30 A.M., the resident stated there hasn't been any activities since the building had COVID-19. She stated she had not been invited to attend activities either. 4. Medical record review for Resident #50 revealed an admission date of 10/01/15. Medical diagnoses (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 09/22/2021 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 included unspecified dementia with behavioral disturbances. she was severely cognitively impaired and was rarely or never understood. Review of the care plan dated 08/03/21 revealed Resident #50 had a potential for alteration in activities. She was interested in: puzzles, bingo, cards, arts and crafts, music, reading, church, pet visits, television, movies, family visits, and being outside. Due to resident cognitive level she is unable to participate in most of her interest, however she does enjoy singing, one on ones, and any social stimulations. Little interest or pleasure in doing things per interview. Interventions was to arrange one on one contacts with the resident. Staff to escort resident to and from activities. Review of activity calendar dated 09/13/21 revealed crafts at 10:15 A.M., trivia at 12:30 P.M. and music at 4:30 P.M. music. Review of activity calendar dated 09/14/21 revealed crafts at 10:15 A.M., exercise at 11:30 A.M. trivia at 12:30 P.M., bingo at 2:00 P.M. and board games at 3:00 P.M. board games. Observations on 09/13/21 and 09/14/21 of the scheduled activity times revealed no activities taking place on the memory care unit. Residents #66, #13, #6 and #50 were not observed participating in any of the scheduled activities. During observation on 09/14/21 at 10:20 A.M. to 10:30 A.M., when the craft activity was supposed to be held, Activity Director (AD) #14 and Activity Aide (AA) #69 were outside at the table smoking cigarettes. During interview on 09/15/21 at 10:45 A.M., AD #14 stated the activity calendar was not being followed on 09/13/21 and 09/14/21 and stated the scheduled activities did not take place. She confirmed she was outside smoking when there should have been an activity on the memory care unit on 09/14/21 at 10:15 A.M. for crafts. During interview on 09/15/21 at 11:15 A.M., AA #69 stated there were only two activities held on the memory care unit on 09/13/21 and 09/14/21. She confirmed on 09/14/21 at 10:20 A.M. she was outside smoking when there was supposed to be an activity of crafts being conducted at 10:15 A.M. on the memory care unit. 5. Record review revealed Resident #24 was admitted on [DATE]. His diagnoses included schizoaffective disorder, bipolar type, hyperlipidemia, anemia, ataxia, major depressive disorder, paraplegia, cellulitis of right lower limb. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the Annual Activity assessment dated [DATE] revealed the resident enjoys smaller group activities. Resident #24 enjoys playing cards, bingo, sports, and reading the newspaper. His hobbies included fishing and hiking. Observation on 09/13/21 at 10:39 A.M. revealed a large activity calendar posted on the wall in the dining room area for the 400 and 500 hallways. The large calendar was completely blank. During interview on 09/13/21 at 10:39 A.M., State Tested Nursing Assistant (STNA) #28 confirmed the large activity calendar on the wall was blank. (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 09/22/2021 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 During interview 09/13/21 at 10:50 A.M., AD #14 stated she had not posted the calendar. Level of Harm - Minimal harm or potential for actual harm During interview on 09/14/21 09:46 A.M., Resident #24 stated he does not attend activities currently because the facility does not have them scheduled due to COVID. Residents Affected - Some During observation on 09/14/21 at 12:33 P.M. and 12:45 P.M., residents were finishing the lunch meal on the 300 hall dining room and the 400/500 hall dining room. The activity calendar listed trivia at 12:30 P.M., but no activity was being held. On 09/14/21 at 12:40 P.M., AD#14 was observed at the front desk of the facility. At 12:46 P.M., AD#14 was observed standing in a room and talking with another employee. During observation on 09/14/21 at 03:01 P.M., no activities were being held on the Memory Care Unit, 300 and 400/500 hall. The activity scheduled at 3:00 P.M. was Board Games. At 3:16 P.M., AA $#69 was pushing a flatbed cart with trash on it throughout the facility. During observation on 09/15/21 at 09:35 A.M., the activity calendar listed coffee as the activity at 9:30 A.M. on all units. No activity was being held on the Memory Care Unit, 300 Hall, 400/500 hall at this time. During interview on 09/15/21 at 10:44 A.M., AD #14 stated the activities were not happening at the times posted on the calendar. AD #14 stated this was due to the department being stretched thin with many tasks. During interview on 09/15/21 at 11:24 A.M., AA #69 stated she does not always follow the activity calendar. AA#69 stated the times are not accurate on the calendar because activities are scheduled at 12:30 P.M. and she will assist residents in the dining room during that time. Review of the policy titled Activity Department Policy, revised on 03/01/07, revealed the Activity Department was responsible for planning and scheduling an Activity Program, consisting of stimulating and therapeutic activities, diverse focus, and consistent with resident's wishes and needs. the AD will develop a monthly calendar. Large calendars will be posted on each unit by the first of the month. The calendar will implemented as written. When cancellations and changes are unavoidable they will be announced in the morning and afternoon. Changes and substitutions will be noted on the daily participation log. 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 09/22/2021 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to manage a resident's pain. This affected one (Resident #41) of two residents reviewed for pain management. The census was 68. Residents Affected - Few Findings include: Medical record review revealed Resident #41 was admitted on [DATE]. Medical diagnoses included congestive heart failure, diabetes, fibromyalgia, cancer of the female breast, emphysema, cellulitis bilateral lower extremities and osteoarthritis. Review of quarterly Minimum Data Set (MDS) assessment, dated 07/26/21, revealed Resident #41 was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. She received scheduled and as needed pain medication. Review of the physician orders dated 05/15/20 revealed Motrin, 800 milligram (mg) by mouth every eight hours. On 06/06/21, Lyrica 100 mg, one capsule three times a day for neuropathy was added. On 06/16/21, the physician added Norco 7.5-325 mg, one tablet every six hours as needed for pain. Review of Medications Administration Record (MAR) from 07/01/21 through 07/31/21 revealed out of 59 administrations of the as needed Norco, 19 of the administrations the resident rated her pain a ten on a one to ten scale; there were 18 times the resident rated her pain a nine; and 15 times, she rated her pain an eight. Review of care plan dated 08/02/21 for Resident #41 revealed she was at risk for alteration in comfort related to osteoarthritis, neuropathy, fibromyalgia and complaints of generalized pain. Interventions were to administer medications as ordered. Notify physician for review of or change in pain medications as needed. Pain assessment per facility policy, offer non-pharmacological interventions and encourage with proper body alignments. Review of the MAR from 08/01/21 through 08/31/21 revealed out of 38 administrations of Norco, 13 times the resident rated her pain a ten; 29 times, she rated the pain a nine; and 23 times, she rated the pain an eight on a one to ten scale, with one being very little pain and a ten, severe pain. Review of the MAR from 09/01/21 through 09/15/21 revealed out of 32 administrations of Norco, the resident rated her pain a ten seven times; 12 times, she rated it a nine; and eight times, she rated her pain an eight on a one to ten scale. Review of the pain assessment dated [DATE] revealed Resident #41 has generalized pain that was dull or throbbing. She experienced pain frequently during the past five days, the fall made the pain worse and medication helped alleviate the pain. The resident rated her pain for the past five days as a nine on a one to ten scale. During interview and observation on 09/13/21 at 1:07 P.M., the resident was in her wheelchair. When she repositioned herself, she winced and said she had back pain on her lower back on the right side. She rated the pain a ten on a one to ten scale. She stated her pain was not controlled and she had asked for an increase in her pain medications, but the nurses say they can only provide what the physician had ordered. She stated her pain was in her knees also and it keeps her awake at night and (continued on next page) 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 09/22/2021 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 0697 at times the pain made her cry. Level of Harm - Minimal harm or potential for actual harm During interview on 09/16/21 at 1:24 P.M., Unit Manager (UM) #31 stated the resident's pain ratings were high. She stated if had known the pain levels were that high, she would have called the physician and let them know and see if they wanted to increase the pain medication dose for the resident. Residents Affected - Few Review of policy titled Pain Assessment and Management dated 03/31/16 revealed assessment and adequate treatment of pain is central to the management of the physical and psychological well-being of the residents. The alert and oriented resident may be asked to describe his/her pain status. Pertinent information may include: Numerical rating scale of 0-10 with zero being no pain and ten being the most severe pain the resident can imagine. Verbal descriptor scale; mild, moderate, severe, very severe/horrible. The resident's expectation for pain relief; can he or she live with the pain at the current level, and if not, how much relief is needed to live comfortably. Evaluate the residents response to interventions and notify the physician as needed. 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 09/22/2021 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview, record review and review of Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to ensure non-licensed nursing staff demonstrated competencies in skills and techniques necessary to care for residents needs prior to providing care and services to residents. This affected two Staff #38 and #250 of five personnel files reviewed. This had the potential to affect all 67 residents who resident in the facility. Findings included: 1. Review of the personnel file for Staff #38 revealed a hire date of 04/06/21. Staff #38 was hired as Non-Certified Nurse Aide under the staffing waiver program for COVID-19. Staff #38 was not a State Tested Nursing Assistant (STNA). The personnel file contained a certificate which indicated Staff #38 completed an eight-hour online training for Temporary Nurse Aide. There was no documentation of competencies being evaluated prior to Staff #38 providing care and services to residents. The file contained the following competency documents: a. Competency documented titled Staff member will demonstrate proper use of the EZ stand equipment for transfers and weights dated 04/16/21 revealed Staff #38 signed the preceptor line and no additional preceptor signed off on the competency demonstration. b. Competency documented titled Staff member will demonstrator proper use of the EZ lift equipment dated 04/16/21 revealed Staff #38 signed the preceptor line with no additional preceptor for competency demonstration. c. Competency documented titled Staff member will demonstrate proper procedures for transferring client from bed to wheelchair dated 04/16/21 revealed Staff #38 signed the preceptor line with no additional preceptor for competency demonstration. d. Competency documented titled Staff member will demonstrator proper use of the EZ lift equipment dated 04/23/21 revealed the preceptor signature line was blank. e. Competency documented titled Staff member will demonstrate proper procedures for transferring client from bed to wheelchair dated 04/23/21, revealed the preceptor signature was blank. f. Competency documented titled Staff member will demonstrate proper use of the EZ stand equipment for transfers and weights dated 04/23/21 revealed preceptor signature line was blank. 2. Review of the personnel file for Staff #25 revealed a hire date of 09/01/21 as a Non-Certified Nurse's Aide due to staffing waiver program for COVID-19. Staff #25 was not a STNA. There was no documentation of competencies being evaluated prior to Staff #25 providing care and services to residents. Interview with Human Resources Staff (HR) #2 on 09/16/21 at 12:00 P.M. verified Staff #25 and 38 were actively working in the facility as Non-Certified Nurse's Aide under the COVID-19 staffing waiver. HR #2 verified Staff #25 and #38 were not STNA's and there was no documented evidence of Staff #25 and #38 having demonstrated competencies in skills and techniques to care for residents. (continued on next page) 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 09/22/2021 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review CMS memorandum titled Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 dated 04/08/21 and reference number QSO-21-17-NH revealed in order to help with nursing homes staffing shortage, CMS provided a blanket waiver for the nurse aide training and certification requirements, except for requirements that the individual employed as a nurse aide be competent to provide nursing and nursing related services. Documented indicated the individual could continue to work beyond the four months as long as the nursing home ensured that the nurse aide could demonstrate competency skills and techniques need to care for residents. 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 09/22/2021 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 Based on record review, observation, interview, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to ensure visitors wore personal protective equipment (PPE) in the facility to prevent the spread of Coronavirus (COVID-19), failed to screen visitors upon entry to the facility, failed to ensure staff wore PPE in a manner to prevent the spread of infectious diseases which included COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19 and failed to ensure an employee who exhibited potential signs and symptoms related to COVID-19 and was not allowed to work. This had the potential to affect all 68 residents residing in the facility. Residents Affected - Many Findings include: 1. Observation on 09/13/21 at 3:28 P.M. on the facility's Tri-state Unit revealed two visitors in the room of Resident #54. During observation of dining room of the secured Carolina Unit on 09/13/21 at 4:50 P.M., two visitors were sitting at the dining table with Resident #4. One visitor had no face covering and the second visitor had her mask looped around her ears and down below her chin. During interview at the time of the observation, Registered Nurse (RN) #3 stated the two visitors were not wearing the proper PPE or wearing it correctly. During Observation the Virginia Unit on 09/14/21 at 2:05 P.M. revealed a visitor in Residents #51's room. Review of the facility's visitor log dated 09/13/21 through 09/16/21 revealed 23 visitors were screened upon entering the facility. Interview with LPN #77 on 09/16/21 at 4:00 P.M. stated facility visitation was stopped during the first round of testing on 09/10/21, however resumed once it was determined there were no additional staff or resident positive COVID-19 cases on 09/10/21. During interview on 09/13/21 at 4:55 P.M., Human Resources Staff (HR) #2 indicated Resident #4's visitors signed in on one line of the visitors log but stated there was no documented evidence the visitors were screened and a body temperature was recorded. HR #2 stated she was not aware visitors entered the facility without masks in place or being screened for COVID-19. HR #2 stated Resident #4's visitors come daily and must have let themselves in. Review of CMS memo titled QSO-20-39-Nursing Home (NH) titled Nursing Home Visitation - COVID-19 revised on 04/27/21, revealed all visitors should be screened for signs and symptoms of COVID-19 when entering facility, should follow all CDC guidance and wear a face mask/ covering while in the facilities. 2. Review of the medical record of Resident #01 revealed an admission date of 05/27/21. Review of the physician's orders for Resident #1 revealed an order dated 09/13/21 at 7:00 A.M. to maintain droplet/contact precautions related to shortness of breath. (continued on next page) 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 09/22/2021 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 Residents Affected - Many During observation on 09/13/21 at 11:43 A.M., the door to Resident #1 room contained notification of droplet and contact precautions, indicating the need to wear a gown. Licensed Practical Nurse (LPN) #87 was at the resident's bedside administering medication and not wearing a protective gown. During interview on 09/13/21 at 11:44 A.M., LPN #87 stated she did wear a gown when entering Resident #1's room and verified the resident was on droplet and contact precautions. During observation on 09/16/21 at 8:00 A.M., State Tested Nurse Aide (STNA) #41 provided care to residents on the Tristate Unit with no eye protection. During interview on 09/16/21 at 8:05 A.M., STNA #41 stated she forgot to put on the eye protection at the beginning of her shift. During observation on 09/16/21 at 1:00 P.M., STNA #63 provided direct care to Resident #47 in the common dining area of the Virginia Unit with no eye protection. STNA #47 pushed resident in her wheelchair down the common hallway, entered and exited the resident's room. During interview on 09/16/21 at 1:10 P.M., STNA #63 stated she forgot to put on the eye protection. Review of the CDC's article Transmission-Based Precautions (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html) revealed contact precautions include the need to wear a gown for all interactions that may involve contact with the patient or the patient's environment and to don PPE upon room entry and properly discard before exiting the patient room. Review of the CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html., revealed Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. Staff should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Guidelines revealed PPE for health care personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions using a gown, gloves, and eye protection. Review of the CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html updated 10/10/21 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed facility should Implement Universal use of PPE for HCP which included Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) and should be worn during all patient care encounters. 3. Review of facility COVID-19 testing log revealed Housekeeper (HK) #61 tested positive for COVID-19 on 09/10/21. Review of the facility schedule revealed HK #61 worked in the facilities Tri-State Unit on 09/07/21. HK #61 called off sick on 09/08/21. He returned to work on 09/09/21 and worked on the facility's Virginia and Carolina units. On 09/10/21, the schedule documented HK #61 off and a plus sign next to his name. (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 09/22/2021 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 Residents Affected - Many Review of a call off/absenteeism report revealed on 09/08/21 at 6:00 A.M., HK #61 called off for his shift due to a migraine with muscle and body aches. During interview on 09/16/21 at 4:00 P.M., LPN #77 stated on 09/07/21, HK #61 tested negative for COVID-19. On 09/08/21, HK #61 called off work because of a headache. On 09/09/21, HK #61 worked in the building. On 09/10/21, HK #61 tested positive for COVID-19. LPN #77 further affirmed HK #61 was undergoing routine COVID-19 testing prior to testing positive because he was not vaccinated. During interview on 09/16/21 at 5:55 P.M., the Director of Nursing (DON) verified visitation was not suspended for a full 14 days when HK #61 tested positive for COVID. Review of the CMS QSO-20-39-NH-revised, dated 04/27/21, revealed, when a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation on the affected unit until at least one round of facility-wide testing was completed and no new cases were discovered. Additionally, the facility should suspend visitation on the affected units until the facility meets the criteria to discontinue outbreak testing which included 14 days of negative testing for HCP and residents. Review of the employee screening checklist revealed, anyone experiencing symptoms, including headache and muscle or body aches in the last 48 hours was not permitted to enter the facility until symptoms had subsided for more than 48 hours. Review of the facility policy titled, Coronavirus Testing, last updated 05/10/21, revealed staff with signs or symptoms of COVID-19, vaccinated or not vaccinated, will be tested, and are expected to be restricted from the facility pending the results of COVID-19 testing. Review of CDC guidelines titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631030205033) updated 09/10/21 revealed HCP who are symptomatic, regardless of vaccination status, should be restricted from work pending evaluation for SARS-CoV-2 infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365554 If continuation sheet Page 14 of 14