Inspection visit
Inspection
28 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 28 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, observation, resident interview, staff interview, and review of the facility policy, the
facility failed to ensure resident call lights were in reach and footrests were placed on wheelchair per
resident's preference. This affected two (#10 and #60) of 17 residents sampled. The census was 63.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #10 revealed an admission date of 05/12/22 with a diagnosis
of paraplegia.
Review of the Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #10 was mildly
cognitively impaired and required extensive assistance of one to two staff with activities of daily living
(ADLs).
Review of the care plan dated 05/16/22 revealed Resident #10 had an ADL self-care performance deficit
related to activity intolerance, disease process paralysis due to gunshot wound, hemiplegia, impaired
balance, limited mobility, limited range of motion, musculoskeletal impairment, pain, shortness of breath.
Interventions included staff to assist resident with mobility and adaptive devices.
Review of the care plan dated 05/16/22 revealed Resident #10 had impaired physical mobility related to
decreased range of motion, neuromuscular impairment, pain/discomfort, partial paralysis (hemiplegia), right
sided neglect. Interventions included call light in reach.
Observation on 008/03/22 at 4:00 P.M. revealed Resident #10 was up in his wheelchair and his call light
was not in reach and his footrests were not on his wheelchair.
Interview on 08/03/22 at 4:00 P.M. with Resident #10 confirmed the aides had gotten him up in his chair
using the Hoyer lift. The staff had left his call light attached to wall and he was unable to reach it. Resident
#10 confirmed he thought they were coming back to put his footrests on his wheelchair so he could wheel
himself out to the smoking area. Resident confirmed it was not safe for him to propel himself in the
wheelchair with footrests in place because his legs were paralyzed.
Interview on 08/03/22 at 4:03 P.M. with Licensed Practical Nurse (LPN) #300 confirmed Resident #10's call
light was out of reach and his footrests were not on his wheelchair. LPN #300 further confirmed Resident
#10 was able to use his call light and it should be left within his reach. LPN #300 further confirmed
resident's footrests need to be on his wheelchair for safety.
2. Review of medical record for Resident #60 revealed an admission dated of 12/13/19 with a
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 25
Event ID:
366175
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0558
diagnosis of schizoaffective disorder.
Level of Harm - Minimal harm
or potential for actual harm
Review of the MDS for Resident #60 dated 07/08/22 revealed resident was cognitively impaired and
required extensive assistance with ADLs.
Residents Affected - Few
Observation on 08/15/22 at 8:24 A.M. revealed Resident #60 was sitting up in his wheelchair next to his
bed and his call light was hanging on the wall out of the resident's reach.
Interview on 08/15/22 at 8:24 A.M. with Resident #60 confirmed his aide got him up in his wheelchair but
didn't give him his call light and he wasn't able to reach it.
Interview on 08/15/22 at 8:25 A.M. with State Tested Nursing Assistant (STNA) #235 confirmed she had
assisted Resident #60 into his wheelchair and did not place his call light within reach before leaving the
room.
Review of the facility policy titled Answering the Call Light, dated March 2021, revealed when the resident is
in bed or confined to a chair be sure the call light is within easy reach of the resident.
This deficiency substantiates Complaint Number OH00133445.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 2 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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
record review, staff interview, and review of the facility policy, the facility failed to ensure the record
accurately reflected the resident's preferred code status for two (#25 and #263) of four residents reviewed
for advanced directives. The census was 63.
Findings include:
1. Review of the medical record for Resident #25 revealed and admission date of 10/16/19 with a diagnosis
of cerebral infarction.
Review of Resident #25 physician order, dated 09/01/21, revealed the resident's code status was Do Not
Resuscitate Comfort Care (DNRCC)-Arrest.
Review of the care plan for Resident #25, dated 05/05/22, identified an advanced directive. Interventions
included: resident had a court appointed legal guardian, resident had memory and cognitive issues and
needed help in making important decisions, resident's code status was DNRCC-Arrest.
Review of progress note per nurse practitioner (NP) for Resident #25 dated 07/13/22 revealed resident's
code status was DNRCC-Arrest.
Review of paper medical record for Resident #25, under the advanced directives tab in the chart, revealed
two advanced directive forms were noted. There was a form dated 06/24/15 signed by the resident's
physician and resident's representative indicating resident's code status was DNRCC-Arrest. On top of that
form was a form dated 06/05/19 signed by the resident's physician and representative indicating resident's
code status was DNRCC.
Interview on 08/03/22 at 11:52 A.M. with Licensed Practical Nurse (LPN) #300 confirmed Resident #25's
correct code status was DNRCC, not DNRCC Arrest, and the resident's record did not consistently reflect
his correct code status.
2. Review of the medical record for Resident #263 revealed an admission date of 07/30/22 with a diagnosis
of affective mood disorder.
Review of the admission physician orders for Resident #263 revealed there were no orders regarding code
status for resident.
Review of the paper medical record for Resident #263 revealed there were no papers indicating resident's
preferred code status.
Review of the progress notes for Resident #263 revealed there was no documentation of the resident's
preferred code status.
Interview on 08/01/22 at 12:15 P.M. with LPN #575 confirmed the resident's code status should be in the
front of the chart and should be included in the admission physician orders. LPN #575 further confirmed
there was no information in the resident's medical record and the resident's paper medical record regarding
code status and if the resident were to code right now she would be unsure how to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 3 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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
proceed in accordance with the resident's wishes.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 08/01/22 04:03 PM. with the Regional Director of Clinical Operations (RDCO) #580 confirmed
code status is supposed to be addressed when a resident is admitted . RDCO #580 confirmed Resident
#263 was admitted on [DATE] and his code status was not addressed, and his wishes added to the medical
record until later in the day on 08/01/22, two days after admission.
Residents Affected - Few
Review of the facility policy titled Advanced Directives, dated December 2016, revealed advanced directives
will be respected in accordance with state law and facility policy. Prior to or upon admission the social
services director or designee will inquire of the resident and his/her family members or representatives
about the existence of any written advanced directives. Information about the resident's advanced directive
will be displayed prominently in the resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 4 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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.
Based on observation, staff interview and review of facility policy, the facility failed to ensure residents had a
safe and clean environment. This affected nine residents (#7, #8, #11, #20, #21, #22, #23, #24, and #25)
who were identified by the facility as smoking. The facility census was 69.
Findings include:
Observations on 09/27/22 at 1:01 P.M. revealed nine Residents (#7, #8, #11, #20, #21, #22, #23, #24, and
#25) smoking on the outside patio. Further observations revealed numerous cigarette butts which littered
the area and numerous cigarette butts in the trashcan.
Interview with Activities Staff #50 on 09/27/22 at 1:01 P.M. revealed she was tasked with monitoring the
smokers. Activities Staff #50 verified the numerous cigarette butts littering the smoking area.
Review of the undated facility policy titled Smoking revealed the facility would allow residents the ability to
smoke while maintaining facility safety.
This deficiency is a recite to the annual survey completed on 08/15/22.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 5 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on observation, record review, staff interviews, and policy review, the facility failed to ensure an
injury of unknown origin was reported to the administrator and to the state agency in a timely manner. This
affected one (#43) out of one resident reviewed for abuse. The facility census was 63.
Findings include:
Review of the medical record for Resident #43 revealed an admission date of 06/08/18. Diagnoses included
repeated falls, hyperlipidemia, major depressive disorder, dementia in other diseases classified elsewhere
with behavioral disturbance, hypertension, muscle weakness, insomnia, and hypotension.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/18/22, revealed this resident
had severely impaired cognition. This resident was assessed to require extensive assistance for bed
mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating.
Review of the nursing progress note dated 07/17/22 revealed the resident was found on the floor in the
hallway in front of a doorway on her left side. The resident was assessed with no pain, discomfort, or facial
grimacing identified.
Review of the facility form titled Fall Investigation Worksheet revealed the resident had a fall on 07/17/22.
The investigation indicated the resident placed herself on the floor and started crawling around. No injuries
were documented on the form.
Review of the nursing progress note dated 07/18/22 revealed the resident was assessed as part of a fall
follow-up with no new skin issues identified.
Review of the nursing progress note dated 07/19/22 revealed the resident was assessed again for a fall
follow-up with no new issues or concerns documented. The note also indicated there were no latent injuries
noted.
Review of the nursing progress note dated 07/20/22 revealed the resident was assessed for a fall follow-up
with no injuries identified, including no bruising noted.
Review of the facility form titled CareCore Health Skin Review, dated 07/25/22, revealed there were no new
skin issues noted. The section for the location and description of any skin issues is blank. The section for
the type of skin issue has no issues marked, including the box for bruising.
Review of the nursing progress note dated 07/31/22 at 6:40 A.M. revealed the nurse was called to the
resident's room because the aide reported the resident's right eye was black and wasn't like that when she
worked the other night. The note indicated the resident had a fall the previous week.
Observation on 08/01/22 at 10:47 A.M. revealed Resident #43 had black and purple discoloration to her
right eyelid.
Interview on 08/01/22 at 4:37 P.M. with the Administrator confirmed the progress note was entered at 6:40
A.M. on 07/31/22.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 6 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 08/01/22 at 4:49 P.M. with the Administrator confirmed the facility was not informed about the
resident's bruised eye by the agency nurse, which was the reason for the facility not filing a Self-Reported
Incident (SRI). The Administrator reported the agency nurse used her judgement and determined the injury
must have occurred from the fall.
Interview on 08/03/22 at 10:07 A.M. with State Tested Nursing Assistant (STNA) #255 revealed she last
worked on 07/28/22 and did not remember the resident's eye looking as bruised as it did today.
Interview on 08/03/22 at 5:35 P.M. with Registered Nurse (RN) #570 revealed Resident #43 had a bruise on
her right eyelid that looked red and purple, which RN #570 identified as newer bruising as well as areas of
yellow that indicated healing.
Interview on 08/04/22 at 3:10 P.M. with the Director of Nursing (DON) verified the agency nurse did not
notify the facility of the bruising to Resident #43's eye, but would have been expected to. The DON reported
the proper response would have been to file an SRI and begin an investigation.
Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and
Investigating, revised 04/2021, revealed if resident abuse, neglect, exploitation, misappropriation of resident
property or injury of unknown source is suspected, the suspicion must be reported immediately to the
administrator and to other officials according to state law.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 7 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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.
Based on medical record review, observations and staff interviews the facility failed to ensure care plans
were updated or revised for residents residing on the secured unit. This affected three Residents (#17, # 28
and #52) of the 17 sampled residents. The facility identified 21 residents who resided on the secured unit.
The facility census was 63.
Findings included:
1. Review of medical record for Resident #17 revealed an admission date of 04/27/22. Diagnosis included
dementia, suicide attempts, multiple fractures secondary to motor vehicle accident (MVA), schizoaffective
disorder, and anxiety. The resident was placed in the secured unit upon admission.
Review of health elopement risk screening dated 04/27/22 and 06/03/22 revealed Resident #17 was
cognitively impaired with poor decision-making skills, had diagnosis of dementia, ambulated independently
with no hearing vision problems.
Review of plan of care for Resident #17 did not identify the resident required a secured unit.
Observations on 08/01/22 from 9:30 A.M. to 4:30 P.M. and 08/02/22 from 6:30 A.M. to 4:30 P.M. revealed
Resident #17 resided on the secured unit.
2. Review of medical record for Resident #28 revealed an admission date of 03/04/22. Diagnosis included
dementia with behaviors, depression, Alzheimer's disease, and psychosis. The resident was placed in the
secured unit upon admission.
Review of physician orders dated 07/01/22 for Resident #28 revealed resident may reside in secured unit
related to dementia.
Review of health elopement risk screening dated 07/01/22 revealed Resident #28 was cognitively impaired
with poor decision-making skills, had diagnosis of dementia, ambulated independent, had hearing and
vision problems, and wandered aimlessly and Resident continued to reside on women's locked unit.
Review of plan of care for Resident #28 did not identify the resident required a secured unit or any
interventions to address the resident's wandering.
Observations on 08/01/22 from 9:30 A.M. to 4:30 P.M. and 08/02/22 from 6:30 A.M. to 4:30 P.M. revealed
Resident #28 resident resided on the secured unit.
3. Review of medical records for Resident #52 revealed an admission date of 01/04/22. Diagnosis included,
but not limited to, dementia, schizoaffective disorder, adjustment disorder and cerebral infarction. The
resident was placed in the secured unit upon admission.
Review of physician orders for Resident #52 dated 01/04/22 revealed resident was ordered to reside in
secured unit related to dementia.
Review of health elopement risk screening dated 07/12/22 revealed Resident #52 was cognitively
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 8 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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
impaired with poor decision-making skills, had diagnosis of dementia, ambulated independently and
resident wandered aimlessly. Notes indicated Resident continued to reside on locked dementia unit with no
issues.
Review of plan of care for Resident #52 did not identify the resident required a secured unit or any
interventions to address the resident's wandering.
Observations on 08/01/22 from 9:30 A.M. to 4:30 P.M. and 08/02/22 from 6:30 A.M. to 4:30 P.M. revealed
Resident #52 resident resided on the secured unit.
Interview with Director of Nursing (DON) on 08/04/22 at 4:15 P.M. verified Resident #17, #28 and #52 did
not have care plans addressing their wandering and the need to reside on a secured unit. The DON stated
her expectations were for residents to have individualized care plans which addressed residents being
admitted to the secured unit.
Review facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/01/22, reveled a
comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the
resident's physical, psychosocial and functional needs is developed and implemented for each resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 9 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0676
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, medical record review, staff interview and review of facility policy, the facility failed to
ensure bed rails to assist with bed mobility were applied to the bed for one (#60) of 17 residents sampled
for activities of daily living (ADLs). The facility census was 63.
Residents Affected - Few
Findings included:
Review of medical record for Resident #60 revealed an admission date of 12/13/19. Diagnosis included
schizoaffective disorder, bipolar, dementia with behavioral issues, falls, anxiety, and weakness.
Review of quarterly side rail screening, dated 07/07/22 by Licensed Practical Nurse (LPN) #285, revealed
Resident #60 had weakness and requested side rails for sense of security, to move up and down in bed,
entering bed more safely, transferring more safely and to avoid rolling out of bed. Assessment indicated
side quarter side rails were recommended to help resident position self.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/08/22, revealed Resident #60 had
severely impaired cognition, had no behaviors, did not reject care, and was dependent or required
extension supervision with activities of daily livings (ADLs).
Review of care plan for Resident #60 indicated resident had ADL self-care deficit related to activity
intolerance, confusion, dementia disease process fatigue impaired balance and limited mobility
Interventions included half assist bars per resident's request to assist with turning, repositioning and bed
mobility.
Observation on 08/01/22 at 3:00 P.M. revealed Resident #60 lying in bed and with no bed rails in place.
Observation revealed resident appeared to be having a difficult time with bed mobility and repositioning.
Interview with State Tested Nurse's Aide (STNA) #220 at same time verified resident seemed to have a
difficult time with bed mobility and repositioning and verified Resident #60 had no rails in place. STNA #220
stated she had never witnessed resident's bed with any rails in place and did not know if rails were ordered
Interview on 08/01/22 at 3:10 P.M. with Registered Nurse (RN) #565 verified resident had no rails in place
and there were no active orders for bed rails.
Observation on 08/02/22 at 6:30 A.M. revealed Resident #60 lying in bed with no rails affixed to bed.
Interview on 08/02/22 at 1:05 P.M. with LPN #285 stated she had never witnessed Resident #60's bed
having bed rails installed. LPN #285 verified Resident #60 requested quarter rails on 07/07/22 for bed
mobility and these should have been installed. LPN #285 additionally stated she is the one that assessed
resident and forgot to order the quarter bed rails.
Review the facility policy titled Bed Safety, dated 12/01/07, revealed the facility would strive to provide a
safe sleeping environment for resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 10 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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
Based on record review, observation, resident interview, staff interview, and review of the facility policy, the
facility failed to ensure residents received proper nail care. This affected three (Resident #7, #25, #42) of
four residents sampled for activities of daily living (ADLs.) The facility census was 63.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #7 revealed an admission date of 04/27/22 with a diagnosis of
myopathy.
Review of the Minimum Data Set (MDS) assessment, dated 08/03/22, revealed Resident #7 was cognitively
impaired and required extensive assistance of one staff with ADLs.
Review of the care plan for Resident #7, dated 08/02/22, revealed an ADL self-care deficit. Interventions
included assist with ADLs and keep nails short and clean.
Review of the care plan for Resident #7, dated 08/02/22, revealed the resident had the potential for
impaired skin integrity and was at risk for skin tears. Interventions included staff should assist with hygiene
and general skin care.
Observation on 08/01/22 at 3:31 P.M. of Resident #7 revealed the resident's toenails were long, jagged and
needed to be trimmed. The toenail extended past the toe approximately one fourth of an inch.
Interview on 08/01/22 at 3:31 P.M. with Resident #7 confirmed the toenails were long and had not been
trimmed recently.
Interview on 08/01/22 at 3:32 P.M. with Licensed Practical Nurse (LPN) #575 confirmed Resident #7's
toenails were long and jagged and needed to be trimmed.
2. Review of the medical record for Resident #25 revealed and admission date of 10/16/19 with a diagnosis
of cerebral infarction.
Review of the MDS assessment, dated 07/27/22, revealed resident was cognitively impaired and required
extensive assistance of one to two staff with ADLs.
Review of the care plan for Resident #25, dated 04/09/21, revealed resident had an ADL self-care
performance deficit. Interventions included staff to assist resident in keeping fingernails short and clean.
Observation on 08/01/22 at 1:03 P.M. of Resident #25 revealed the resident's fingernails were long and had
debris underneath them. The fingernail extended approximately one quarter inch beyond the end of the
fingers.
Interview on 08/01/22 at 1:03 P.M. with Resident #25 confirmed his fingernails were too long and needed to
be trimmed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 11 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 08/01/22 at 1:04 P.M. with State Tested Nursing Assistant (STNA) #280 confirmed Resident
#25's nails were long and had debris under them. STNA #280 confirmed the resident's fingernails needed
to be trimmed and cleaned.
3. Review of the medical record for Resident #42 revealed an admission date of 07/11/22 with a diagnosis
of diabetes mellitus (DM).
Review of MDS assessment, dated 07/17/22, revealed resident was cognitively intact and required
extensive assistance of one staff with ADLs.
Review of the care plan for Resident #42, dated 07/14/22, revealed an ADL self-care performance deficit.
Interventions included staff should assist resident with ADLs and should ensure resident's fingernails are
kept short and clean.
Observation on 08/01/22 at 1:12 P.M. of Resident #42 revealed the resident's fingernails were long and had
debris underneath them. The fingernail extended approximately one quarter inch beyond the end of the
fingers.
Interview on 08/01/22 at 1:12 P.M. with Resident #42 confirmed his fingernails were too long and needed to
be trimmed.
Interview on 08/01/22 at 1:13 P.M. STNA #220 confirmed Resident #42's nails were too long and had
debris under them. STNA #220 confirmed resident's fingernails needed to be trimmed and cleaned but
since he was a diabetic only the nurse could do that.
Review of the facility policy titled Care of Fingernails and Toenails, dated February 2018, revealed
nail care included daily cleaning and regular trimming and proper nail care could aid in the prevention of
skin problems around the nail bed.
This deficiency substantiates Complaint Number OH00133445 and Complaint Number OH00133627.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 12 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
Based on record review, staff interview, and review of the facility policy, the facility failed to monitor resident
bowel functioning. This resulted in actual harm for Resident #45 when the resident went multiple days with
no bowel movements and was subsequently treated at the hospital for severe fecal impaction. The facility
also failed to ensure compression stockings were in place as ordered. This affected one resident (#45) out
of three reviewed for bowel monitoring and one (#60) of five facility-identified residents with orders for
compression stockings. The facility census was 63.
Residents Affected - Few
Findings include:
1. Review of the medical record for Resident #45 revealed and admission date of 12/20/21 with a diagnosis
of traumatic brain injury (TBI.)
Review of the Minimum Data Set (MDS) assessment, dated 07/07/22, revealed Resident #45 was
cognitively impaired and required extensive assistance of one to two staff with activities of daily living
(ADLs), including toilet use. Resident #45 was incontinent of bowel.
Review of physician orders dated 12/20/21 revealed senna tablets daily for treatment of constipation and
Miralax as needed for constipation.
Review of the February 2022 Medication Administration Record (MAR) for Resident #45 revealed resident
received senna daily but did not receive any doses of Miralax.
Review of the care plan for Resident #45, updated 05/23/22, revealed the resident had an alteration in
bowel elimination; constipation related to immobility, pain medication use, and psychotropic medication use.
Interventions included: administer laxatives per physician orders, assist with toileting as needed, record all
stools, report irregularities to charge nurse, encourage fluid intake as appropriate, note signs and
symptoms of constipation, monitor stool frequency, and follow bowel regimen protocol as needed,
encourage the resident to voice the need to have bowel movements, report to charge nurse any complaints
of abdominal discomfort or difficulty having a bowel movement.
Review of the nurse progress note dated 02/22/22 revealed the resident was found with her gastrostomy
tube (g-tube) dislodged and the resident was unable to verbalize how long the tube had been out. Resident
#45 was sent to the hospital via 911 due to g-tube dislodgement.
Review of hospital records for Resident #45, dated 02/22/22, revealed the resident presented in the
emergency room with a chief complaint of dislodged g-tube. Resident's abdomen was distended and rigid.
The resident was noted with moderately severe constipation and severe fecal impaction causing partial
obstruction of the colon. General surgery was consulted and recommended Resident #45 receive soapsuds
enemas every four hours and Miralax every six hours per g-tube.
Review of nurse progress note for Resident #45 dated 02/23/22 revealed the facility received a report that
resident was being admitted to the hospital for a diagnosis of urinary tract infection (UTI.).
Review of bowel record for Resident #45 for February 2022 revealed there were no bowel movements
recorded for 02/01/22, 02/02/22, 02/03/22, 02/04/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22,
02/10/22, 02/12/22, 02/14/22, 02/15/22, 02/16/22, 02/17/22, 02/19/22, 02/20/22, 02/20/22, 02/21/22,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 13 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0684
02/22/22. Review of bowel record revealed the resident was incontinent of a small amount of formed stool
times one on the each of the following days: 02/11/22, 02/13/22, 02/18/22.
Level of Harm - Actual harm
Residents Affected - Few
Review of nurse progress note dated 02/2622 revealed Resident #45 was readmitted to the facility with no
new orders.
Interview on 08/02/22 at 3:59 P.M. with State Tested Nursing Assistant (STNA) #410 confirmed Resident
#45's bowel record for February 2022 revealed the resident did not have bowel movements on the following
dates: 02/01/22, 02/02/22, 02/03/22, 02/04/22, 02/05/22, 02/06/22, 02/07/22, 02/08/22, 02/09/22, 02/10/22,
02/12/22, 02/14/22, 02/15/22, 02/16/22, 02/17/22, 02/19/22, 02/20/22, 02/20/22, 02/21/22, 02/22/22. STNA
#410 confirmed Resident #45's bowel record for February 2022 indicated resident was incontinent of a
small amount of formed stool times one on the following dates: 02/11/22, 02/13/22, 02/18/22. STNA #410
confirmed staff should inform the nurse if a resident goes three days or longer without a bowel movement
(BM.)
Interview on 08/03/22 at 8:14 A.M. with Licensed Practical Nurse (LPN) #285 confirmed if an aide says a
resident has gone two to three days without a BM the nurse should assess the resident, check for as
needed constipation medications, and call the physician if no results from the as needed medications.
Interview on 08/03/22 at 9:16 A.M. with STNA #255 confirmed the computerized charting system gives the
aide an alert if a resident has gone too long without a BM. STNA #255 confirmed she would notify the
nurse if resident went more than two days without a BM or if they showed signs of abdominal pain.
Interview on 08/03/22 at 12:44 P.M., Regional Director of Clinical Operations (RDCO) #580 confirmed the
facility's bowel protocol per the medical director was if resident had no BM in three days the nurse should
administer Miralax or senna and if still no BM, notify the physician.
Interview on 08/04/22 at 1:55 P.M. with the Director of Nursing (DON) confirmed Resident #45 was sent to
the hospital for a dislodged g-tube on 02/22/22 and at the hospital they discovered the resident had a
severe fecal impaction. The DON further confirmed the bowel record for Resident #45 for February 2022
showed the resident went multiple days without a BM and had only three small BMs recorded for the month
of February 2022 prior to the resident's hospitalization.
2. Review of the medical record for Resident #60 revealed an admission dated of 12/13/19. Diagnosis
included schizoaffective disorder, bipolar, dementia with behavioral issues, falls, anxiety, repeated falls, and
muscle weakness.
Review of physician orders dated 05/24/22 revealed Resident #60 was ordered to have ted hose to bilateral
lower legs.
Review of July and August 2022 treatment administration record (TAR) revealed no documented evidence
of resident having ted hose in place.
Observations on 08/01/22 at 3:00 P. M revealed Resident #60 was lying in bed with no ted hose in place.
Interview with Stated Tested Nurse's Aide (STNA) #220 at this time verified the resident had no ted hose in
place. STNA #220 stated she had never seen Resident #60 wear TED hose.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 14 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0684
Interview 08/01/22 at 3:05 P.M. with Registered Nurse (RN) #565 verified Resident #60 was ordered ted
hose and verified the resident had no ted hose in place.
Level of Harm - Actual harm
Residents Affected - Few
Observations on 08/02/22 from 6:30 A.M. to 12:30 P.M. reveled Resident #60 was seated in his wheelchair
without ted hose in place.
Interview on 08/02/22 at 12:36 P.M. with LPN #285 verified Resident #45 had no ted hose in place. LPN
#285 was observed to look through resident's personal items and stated she could not find any ted hose.
Interview on 08/02/22 at 1:05 P.M. with LPN #285 verified Resident#60 was ordered ted hose but the facility
had nothing in place to record and monitor to ensure resident had ted hose placed and removed. LPN #285
stated she updated the physician orders and added ted hose to the TAR so application could be recorded.
This deficiency substantiates Complaint Number OH00133859.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 15 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff interview, and review of the facility policy, the facility failed to assess and
monitor a pressure ulcer for one (#10) resident. The facility identified four residents with pressure ulcers.
The census was 63.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 05/12/22 with a diagnosis of
paraplegia.
Review of the Minimum Data Set (MDS) assessment, dated 05/16/22, revealed resident was mildly
cognitively impaired and required extensive assistance of one to two staff with activities of daily living
(ADLs). Resident was coded as negative for the presence of pressure ulcers and was at risk for the
development of pressure ulcers.
Review of the pressure ulcer risk assessment for Resident #10 dated 05/12/22 revealed the resident was at
low risk for the development of pressure ulcers.
Review of the care plan for Resident #10 dated 05/16/22 revealed a potential for impairment of skin
integrity and at risk for skin tears, poor tissue integrity, potential for infection related to altered nutritional
state, disease process, immobility, impaired tactile sense, neurological impairment. Interventions included
assist with hygiene and general skin care, keep skin clean and dry, apply protective cream after each
incontinent episode, turn and reposition per protocol, elevate heels from bed surface while in bed utilizing
pillows, and monitor skin risk assessment quarterly.
Review of weekly skin checks per licensed nurse for Resident #10 dated 06/02/22, 06/09/22, 06/12/22
revealed resident's skin was intact.
Review of the nurse progress note by Licensed Practical Nurse (LPN) #390, dated 06/15/22, revealed
Resident #10 had an open area to his sacrum which was identified by the resident's family member. The
physician was notified and an order was given to cleanse area with normal saline, pat dry, apply collagen to
the wound bed and cover with dry clean dressing once daily and as needed.
Review of the medical record for Resident #10 from 06/15/22 to 06/28/22 revealed it did not include an
assessment or measurements of the open area to resident's sacrum first identified on 06/15/22.
Review of the wound physician visit note dated 06/29/22 revealed Resident #10 had a stage IV pressure
ulcer to his sacrum, first noted on 06/15/22, which measured 1.3 centimeters (cm) in length by 0.6 cm in
width by 0.4 cm in depth. Composition of the wound was 90 percent (%) granulation tissue and 10%
slough.
Interview on 08/03/22 at 1:50 P.M. with LPN #390 confirmed Resident #10's representative took a picture of
the wound on resident's sacrum and showed it to her. LPN #390 confirmed the facility did not conduct a
measurement or assessment of the resident's wound until 06/29/22.
Review of the undated facility policy titled Pressure Ulcer/Injury Risk Assessment revealed if a new skin
alteration is noted the nurse should initiate a (pressure or non-pressure) form related to the type of
alteration in skin to document details of the alteration.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 16 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0686
This deficiency substantiates Complaint Number OH00133445.
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:
366175
If continuation sheet
Page 17 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 - Some
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
observations, staff interviews, medical records review, and review of facility policy, the facility failed to
ensure residents environment was free of accident hazards for two (#56 and #60) residents reviewed for
falls. Additionally the facility failed to complete quarterly smoking assessments and utilize identified
protective aprons while smoking for four (#44, #56, #27 and #29) of 13 residents identified by the facility
who smoked. Lastly the facility failed to ensure hazardous chemicals and items were secured on a secured
unit. This had the potential to affect all 21 Residents (#61, #62, #17, #364, #21, #40, #37, #32, #363, #55,
#09, #59, #43, #35, #14, #52, #02, #04, #28, #54, and #01) who resided in the secured unit who the facility
identified as being cognitively impaired and independently mobile. The facility census was 63.
Findings include:
1. Review of medical record for Resident # 56 revealed an admission date of 12/13/19. Diagnoses included
cerebral infarction with hemiplegia, lack of coordination, schizophrenia, muscle weakness, difficult in
walking, dysphagia, convulsions/epilepsy, and vascular dementia.
Review of the most recently completed Minimum Data Set (MDS) assessment, dated 07/04/22, revealed
Resident #56 was cognitively intact.
Review of the fall risk assessment for Resident #56, dated 06/15/22, revealed the resident was unable to
independently come to a standing position.
Review of physician orders dated 09/22/16 revealed Resident #56 was ordered Dycem to the wheelchair at
all times. Review of physician orders dated 11/19/21 revealed an order for anti-tippers to the wheelchair.
Review of the care plan revealed Resident #56 was at risk for falls, had poor balance, weakness, wandered
daily and resident had poor safety awareness. Interventions included anti-tippers to wheelchair and Dycem
(anti-slip) mat to wheelchair.
Observation on 08/01/22 at 9:08 A.M. revealed Resident #56 sitting in a wheelchair inside his room. The
wheelchair had no anti-tippers affixed to wheelchair.
Observation on 08/01/22 from 10:00 A.M. through 2:50 P.M. revealed Resident #56 was situated in a
wheelchair without anti-tippers in place.
Observation and interview on 08/01/22 at 3:00 P.M. with State Tested Nurse's Aide (STNA) #220 verified
Resident #56's wheelchair had no anti-tippers in place and there was no Dycem mat in place. STNA #220
stated she was not aware resident was ordered anti-tippers or a Dycem mat for the wheelchair.
Interview on 08/01/22 at 3:10 P.M. with Licensed Practical Nurse (LPN) #385 verified Resident #56 was
ordered to have anti-tippers affixed to the wheelchair and a Dycem mat due to fall precautions.
Additionally, review of most recent smoking quarterly assessment, dated 08/18/21, revealed Resident #56
had a dexterity problem and required supervision during smoking.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 18 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 - Some
Review of the care plan revealed Resident #56 had potential for injury related to smoking cigarettes.
Interventions included resident would have a smoking assessment quarterly for safety and with any
significant change, provide supervision during smoking, and staff would remind resident to wear an apron.
Observation on 08/01/22 at 1:13 P.M. of residents smoking revealed Resident #56 slouched in his
wheelchair smoking with cigarette ashes falling on his clothes and no smoking apron in place.
Interview with the DON on 08/04/22 at 4:00 P.M. revealed Resident #56 should have had a smoking apron
in place. DON stated she would update the physician orders for Resident #56. The DON also verified the
last smoking assessment for Resident #56 was on 08/18/21. The DON stated residents should have a
smoking assessment quarterly and as needed for significant changes.
2. Review of medical record for Resident #60 revealed an admission dated of 12/13/19. Diagnoses included
schizoaffective disorder, bipolar, dementia with behavioral issues, falls, anxiety, and weakness.
Review of physician orders dated 07/14/21 for Resident #60 revealed the resident was ordered to have
anti-tippers on wheelchair.
Review of the most recently completed MDS assessment dated [DATE] revealed Resident #60 had severely
impaired cognition, had no behaviors, did not reject care, was two-person physical assist and was
dependent or required extension supervision with activities of daily livings (ADLs).
During observations on 08/02/22 at 7:30 A.M. revealed Resident #60 was seated in his wheelchair inside
his room eating breakfast. Further observations revealed resident's wheelchair revealed no anti-tippers
affixed to resident's wheelchair. Continued observation of room revealed a set of anti-tippers lying on the
floor of resident's bathroom.
During interview on 08/02/22 at 8:40 A.M. with LPN # 285 revealed she assisted getting Resident #60 out
of bed and into his wheelchair before breakfast. LPN #285 verified resident was ordered anti tippers and
they were not affixed to his wheelchair.
During observation and interview on 08/02/22 at 9:04 A.M. with Director of Nursing (DON) verified Resident
#60 was ordered to have anti tippers affixed to his wheelchair and verified anti-tippers were not in place.
DON verified the anti-tippers were lying in the bathroom floor. DON stated she would call maintenance to
get the anti-tippers affixed to chair. DON stated her expectations were if residents had anti tippers ordered
for their wheelchairs, they should be in place.
Review of care plan for Resident #60 indicated resident had potential for injuries/falls related to balance
deficit, cognitive impairment, history of falls, weakness. Intervention included anti tippers to rear of
wheelchair to prevent tipping backwards.
3. Review of the medical records for Resident #44, revealed an admission date of 01/17/22. Diagnoses
included epilepsy muscle weakness, anxiety, bipolar, osteoporosis, dysphagia, and cachexia.
Review of most recent smoking assessment, dated 08/25/21, revealed Resident #44 required supervision
during smoking.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 19 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 - Some
Review of the most recently completed Minimum Data Set (MDS) assessment dated [DATE] revealed
Resident #44 was cognitively intact.
Review of care plan for Resident #44 revealed resident was a smoker, required supervision due to poor
decision making and judgement for safety of others and have potential for injury related to smoking.
Interventions included the resident would wear a smoking apron at all times and facility would ensure
resident smoked safely with quarterly smoking assessments.
During observation on 08/01/22 at 1:13 P.M. of residents smoking revealed Resident #44 was actively
smoking without an apron.
Interview with Activities Staff #540 on 08/02/22 at 9:50 A.M. revealed she was tasked with monitoring the
smokers. Activities Staff #540 verified she was not aware if any residents were required to wear a smoking
apron and verified they were not in use when residents smoked.
Interview on 08/04/22 at 4:00 P.M. with the Director of Nursing (DON) verified Resident #44 was smoking
without an apron on and did not have quarterly assessments completed. The DON stated all residents who
smoked should have a smoking assessment quarterly and as needed for significant changes due to
smoking safely.
4. Review of medical record for Resident #27 revealed an admission date of 01/24/19. Diagnoses included
anxiety, Alzheimer's Disease, dementia, chronic pain, and shortness of breath.
Review of most recent smoking quarterly assessment, dated 08/23/21, revealed Resident #27 required
supervision during smoking.
Review of the most recently completed MDS assessment dated [DATE] revealed Resident #27 had
moderately impaired cognition.
Review of care plan for Resident #27 revealed resident had potential for injury related to smoking, was
non-compliant with facilities smoking policy, at risk for harm/injury due to non-compliance and refusal to
follow facility policies. Interventions revealed facility would complete smoking assessments quarterly for
safety, resident would wear a smoking apron, and resident would be educated and reminded of facility
policy to wear a smoking apron and provide supervision during smoking.
Observation on 08/01/22 at 1:13 P.M. of residents smoking revealed Resident #27 was actively smoking
with no smoking apron in place.
Interview on 08/04/22 at 4:00 P.M. with the DON verified Resident #27 was smoking without an apron on
and did not have quarterly smoking assessments completed.
5. Review of medical record for Resident #29 revealed an admission date of 11/12/19. Diagnoses included
muscle weakness, shortness of breath, major depressive disorder, and repeated falls.
Review of most recent smoking quarterly assessment, dated 12/01/21, for Resident #29 revealed required
supervision during smoking.
Review of the most recently completed MDS assessment dated [DATE] revealed Resident #29 was
cognitively intact.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 20 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 - Some
Review of care plan for Resident #29 revealed resident was a smoker and required supervision due to poor
decision making and judgement, and for safety of self and others, had a potential for injury related smoking
cigarettes interventions included resident would be supervised during smoking, have quarterly smoking
assessment and resident to wear a smoking apron at all times.
During observation on 08/01/22 at 1:13 P.M. of residents smoking revealed Resident #29 was actively
smoking with no apron in place
Interview on 08/04/22 at 4:00 P.M. with the DON verified Resident #29 was smoking without an apron on
and did not have quarterly smoking assessments completed.
Review of undated facility policy titled Smoking revealed the facility would allow residents to the ability to
smoke while maintaining facility safety. Policy indicated facility would do quarterly smoking assessments for
Resident safety.
6. Review of medical record for Resident #62 revealed an admission date of 02/11/11. Diagnosis included,
but not limited to, cerebral infarction, schizoaffective disorder, and dementia with behaviors.
Review of MDS dated [DATE] revealed Resident #62 had severely impaired cognition, had no behaviors,
was one-person physical assist and required extensive assistance with ADLs.
During observations on 08/01/22 at 8:55 A.M. in Resident #62's room revealed an unsecured, reddish,
liquid inside a gallon container sitting on resident's bathroom shelf marked floor cleaner.
Interview on 08/01/22 at 9:01 A.M. with Licensed Practical Nurse (LPN) #340 indicated the gallon container
of reddish liquid was a multi-purpose cleaner brought in by Resident #62 daughter to clean the floor. LPN #
#340 stated the chemicals should have been secured in the secured unit.
7. Review of medical record for Resident #62 revealed an admission date of 02/11/11. Diagnosis included,
but not limited to, cerebral infarction, schizoaffective disorder, and dementia with behaviors.
Review of MDS dated [DATE] revealed Resident #62 had severely impaired cognition, had no behaviors,
was one-person physical assist and required extensive assistance with ADLs.
Observations of Resident #62's room on 08/01/22 at 8:55 A.M. revealed an unsecured, reddish, liquid
inside a gallon container sitting on the resident's bathroom shelf marked floor cleaner.
Interview on 08/01/22 at 9:01 A.M. with Licensed Practical Nurse (LPN) #340 revealed the gallon container
of reddish liquid was a multi-purpose cleaner brought in by Resident #62's daughter to clean the floor. LPN
# #340 stated the chemicals should have been secured in the secured unit.
Observation on 08/03/22 at 9:32 A.M. on the women's secured unit revealed a room being used for storage
with the door unlocked and slightly open. The room contained aero linen disinfectant and deodorizer,
Orange Glo wood cleaner, HDX glass cleaner, and Husky disinfectant spray, all had caution labels. There
was also a pair of scissors.
Interview on 08/03/22 at 9:33 A.M. with LPN Unit Manager #390 confirmed the door to the room was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 21 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 - Some
unlocked with no staff present. LPN Unit Manager #390 reported housekeeping staff had just been in the
room and must have left the door unlocked. LPN Unit Manager #390 also confirmed the presence of the
unsecured scissors and the cleaning products with precautionary labels
Observation on 08/03/22 at 10:14 A.M. of a door labeled janitor's closet on the women's secured unit near
the common area revealed the door was unlocked. The closet contained disinfectant spray, bleach, and
toilet bowl cleaner with precautionary labels.
Interview on 08/03/22 at 10:14 A.M. with State Tested Nursing Assistant (STNA) #255 confirmed the door
was unlocked at the time of the observation.
Interview on 08/03/22 at 10:16 A.M. with Housekeeping Staff #500 verified the janitor's closet contained
various cleaning products, including disinfectant spray, bleach, and toilet bowl cleaner marked with the word
danger on the front of the bottle.
The facility identified 21 Residents (#61, #62, #17, #364, #21, #40, #37, #32, #363, #55, #09, #59, #43,
#35, #14, #52, #02, #04, #28, #54, and #01) who resided in the secured unit who were cognitively impaired
and independently mobile.
This deficiency substantiates Master Complaint Number OH00134900.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 22 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on record review, observation, resident interview, staff interview, and review of the facility policy, the
facility failed to ensure medications were secured and not left at the residents' bedside for two (#8 and #46)
residents observed during the survey. The facility census was 63.
1. Review of the medical record for Resident #8 revealed an admission date of 04/29/22 with a diagnosis of
paraplegia.
Review of the Minimum Data Set (MDS) assessment, dated 08/03/22, revealed Resident #8 was cognitively
impaired.
Review of the August 2022 monthly physician's orders for Resident #8 revealed an order dated 04/29/22 for
Zofran every eight hours as needed for nausea and vomiting.
Observation on 08/02/22 at 9:56 A.M. of Resident #8's room revealed there was a plastic cup with a white
pill sitting on top of resident's overbed table.
Interview on 08/02/22 at 9:56 A.M. with Resident #8 confirmed there was plastic cup with a white pill on his
overbed table and he thought the nurse had brought it in last night because he was sick to his stomach, but
he didn't want to take any pills.
Interview on 08/02/22 at 10:05 A.M. with Licensed Practical Nurse (LPN) #340 confirmed the night nurse
had told her in report that Resident #8 had complained of stomach pain last night and she had offered him
a Zofran, but he refused. LPN #340 confirmed she had not been in resident's room yet to assess him and
had noticed the pill in the plastic cup on the resident's overbed table. LPN #340 confirmed the pill in the cup
looked like a Zofran tablet.
2. Review of medical record for Resident # 46 revealed an admission date of 10/27/15. Diagnoses included
Parkinson's disease, schizoaffective disorder, muscle weakness, bipolar disorder, and major depressive
disorder.
Review of physician orders dated 10/16/19 revealed Resident #46 was ordered to receive Nystatin Powder
under breasts every shift. Physician orders dated 02/17/22 revealed Resident #46 was ordered to receive
Voltaren Gel every shift for knee pain.
Review of MDS assessment, dated 07/02/22, revealed Resident #46 had moderately impaired cognition.
Observation on 08/01/22 at 10:30 A.M. of Resident #46's room revealed a basket containing one tube of
Voltaren Gel with a pharmacy label affixed to the box, one box of Nystatin Powder with pharmacy label
affixed to the box and one tube of Nystatin cream. Interview with Resident #46 at the time of the
observation revealed nursing staff left the medication in her room so it was easier to access and so the
resident could remind staff to apply the medications.
Interview on 08/01/22 at 10:37 A.M. with Registered Nurse (RN) #565 verified Resident #46's medications
were being stored in her room. RN #565 stated Resident #46's medications should not have been stored in
her room and should have been secured in the medication cart.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 23 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0761
Review of the facility policy titled Storage of Medications, dated November 2020 revealed the facility should
store all drugs and biologicals in a safe, secure, and orderly manner.
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:
366175
If continuation sheet
Page 24 of 25
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
366175
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carecore at the Meadows
11760 Pellston Court
Cincinnati, OH 45240
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 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility documents, staff interview, and review of the facility policy, the facility failed to
ensure the Medical Director participated regularly as a member of the facility's Quality Assessment
Performance Improvement (QAPI) Committee. This had the potential to affect all residents in the facility. The
census was 63.
Residents Affected - Many
Findings include:
Review of facility QAPI meeting minutes sign-in sheets for July 2021 to August 2022 revealed the facility
held QAPI meetings on the following dates: 07/21/21, 10/19/21, 11/18/21, 01/19/22, 04/20/22, 07/27/22.
The only meeting sign in sheet which included a signature of Medical Director (MD) #585 was the meeting
dated 04/20/22.
Interview on 08/04/22 at 2:00 P.M. with the Director of Nursing confirmed the facility had no record of MD
#585's involvement with the QAPI Committee. MD #585 only participated in the meeting on 04/20/22.
Review of the facility policy titled QAPI Program-Governance and Leadership; dated March 2020, revealed
the Medical Director should serve on the committee which meets at least quarterly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366175
If continuation sheet
Page 25 of 25
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Back to topCitations
28 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0030GeneralS&S Fpotential for harm
List the names and contact information of those in the facility.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
F584 - Safe Environment
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.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
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.
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the August 15, 2022 survey of CARECORE AT THE MEADOWS?
This was a inspection survey of CARECORE AT THE MEADOWS on August 15, 2022. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARECORE AT THE MEADOWS on August 15, 2022?
Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "List the names and contact information of those in the facility."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.