Inspection·August 16, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Resident #19 on 08/15/23 at 11:00 A.M., confirmed the facility had served breakfast on 08/15/23 with plastic cutlery. Resident #19 confirmed the facility frequently served meals with plastic cutlery and this was not his preference. Resident #19 preferred to dine using regular silverware. Review of the Resident Council Minutes dated 06/28/23, revealed the residents' made complaints about the lack of silverware and when the kitchen was short staffed, they had to eat off paper or plastic products. Review of Resident Council Minutes dated 07/26/23 revealed the residents' made complaints about not having a complete set of utensils on the meal trays. Review of the undated facility policy titled Dignity revealed the residents should have a dignified dining experience. This deficiency represents non-compliance investigated under Complaint Numbers OH00145260 and OH00144877. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 2 of 10 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 08/16/2023 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 - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure fall prevention interventions were in place as ordered by the physician. This affected two residents (#50 and #59) of three residents reviewed for falls. The facility census was 76. Findings include: 1) Review of the medical record for Resident #50 revealed an admission date of 01/25/22 with diagnoses including rhabdomyolysis, major depressive disorder, osteoarthritis (OA) hypothyroidism, and hypertension (HTN.) Review of the fall risk assessment for Resident #50 dated 02/22/23, revealed the resident was at risk for falls. Review of the physician orders for Resident #50, revealed an order dated 02/23/23 for the resident to have fall mats to bilateral sides of the bed. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #50 dated 07/07/23, revealed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADLs.) Review of the care plan for Resident #50 updated 08/01/23, revealed the resident had a potential for injuries/falls related to balance deficit, cognitive deficits, disease progression, incontinence, non-compliance. Interventions included the following: fall mats to bilateral sides of the bed, anti-rollbacks to wheelchair, bed in lowest position while in bed, Dycem to wheelchair to prevent sliding, encourage non-skid footwear at all times, encourage to ask/use call light for assistance, and call light within reach. Observation of Resident #50 on 08/15/23 at 9:41 A.M., revealed the resident was in bed and had a fall mat to the left side of the bed but there was no fall mat on the right side of the bed. The bed was not pushed against the wall and there was a space on the floor to the right side of the bed for a fall mat. Interview with Resident #50 on 08/15/23 at 9:41 A.M., confirmed she only had one fall mat and it was placed on the left side of the bed. Resident #50 confirmed she was not sure if she was supposed to have one or two fall mats. Interview with Licensed Practical Nurse (LPN) #520 on 08/15/23 at 9:42 A.M., confirmed Resident #50 had only one fall mat and it was placed to the left side of the bed. LPN #520 confirmed there were no additional fall mats available in the resident's room, and she was unsure if resident's order was for one or two fall mats. Observation of Resident #50 on 08/15/23 at 1:25 P.M., revealed the resident was in bed and had a fall mat to the left side of the bed but there was no fall mat to the right side of the bed. Interview with State Tested Nursing Assistant (STNA) #175 on 08/15/23 at 1:25 P.M., confirmed Resident #50 was in bed and had a fall mat to the left side of her bed, but there was no fall mat to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 3 of 10 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 08/16/2023 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 - Few right side of her bed. STNA #175 confirmed there were no additional fall mats available in Resident #50's room and she was unsure if resident was supposed to have one or two fall mats. Interview with Regional Nurse (RN) #525 on 08/16/23 at 12:18 P.M., confirmed Resident #50 was at risk for falls and injuries from falls. RN #525 further confirmed Resident #50 had a physician's order for resident to have fall mats to bilateral sides of the bed. Review of the August 2023 Treatment Administration Record (TAR) for Resident #50, revealed the staff were signing off on the order for the resident's fall mats to bilateral sides of the bed. 2) Review of the medical record for Resident #59 revealed an admission date of 07/19/23 with diagnoses including alcohol dependence in remission, sick sinus syndrome, chronic kidney disease (CKD), cardiomyopathy, major depressive disorder, and atherosclerotic heart disease. Review of the fall risk assessment for Resident #59 dated 07/19/23 revealed resident was at high risk for falls. Review of the MDS for Resident #59 dated 07/26/23, revealed the resident was cognitively impaired and required extensive assistance of one staff with ADLs. Review of the physician orders for Resident #59, revealed an order dated 07/27/23 for the resident to have bed at lowest position with fall mats in place for safety. Review of the care plan for Resident #59 dated 08/07/23, revealed the resident had the potential for injuries/falls related to balance deficit, cognitive deficits, disease progression, and weakness. Interventions included the following: assist in position for comfort as needed, anticipate needs as able, Dycem to chair, encourage to ask/use call light for assistance, call light within reach, frequent orientation to room, bathroom, call light, and facility, maintain uncluttered environment, monitor safety/preventative devices for application, instruct on use of adaptive equipment as needed, observe and report unsafe conditions, observe for signs and symptoms of pain, medicate per physician orders, pharmacy medication review as needed, provide activities that minimize the potential for falls while providing diversion and distraction, and refer to therapy as needed. Observation of Resident #59 on 08/15/23 at 9:30 A.M., revealed the resident was in bed and there were no fall mats in place. Interview with STNA #175 on 08/15/23 at 9:30 A.M., confirmed Resident #59 did not have falls mats in place and there were no fall mats available in the resident's room. Observation of Resident #59 on 08/15/23 at 1:29 P.M revealed the resident was in bed and there were no fall mats in place. Interview with LPN #530 on 08/15/23 at 1:29 P.M., confirmed Resident #59 did not have falls mats in place and there were no fall mats available in the resident's room. LPN #530 confirmed she was unsure if Resident #59 was supposed to have falls mats or not. Interview with RN #525 on 08/16/23 at 12:18 P.M., confirmed Resident #50 was at risk for falls and injury from falls. RN #525 further confirmed Resident #59 had a physician's order for the resident to have bed at lowest position with fall mats in place for safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 4 of 10 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 08/16/2023 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 Review of the undated facility policy titled Falls and Fall Risk Managing revealed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. This deficiency represents non-compliance investigated under Complaint Number OH00145260. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 5 of 10 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 08/16/2023 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of staffing schedules, staff interviews, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all residents residing in the facility. The facility census was 76 residents. Findings include: Review of the staffing schedules revealed there was no RN scheduled on the following dates: 08/06/23, 08/11/23, 08/14/23, and 08/15/23. Interview with the Administrator 08/16/23 at 2:25 P.M., confirmed the facility did not have an RN working for eight consecutive hours on the following dates: 08/06/23, 08/11/23, 08/14/23, and 08/15/23. Review of the facility policy titled Staffing dated October 2017, revealed the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 6 of 10 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 08/16/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on medical record review, resident interview, staff interview, review of dietary staff schedules, review of menus, and review of the facility policy, the facility failed to ensure residents were fed meals per the facility menu. This affected all residents in the facility with the exception of two residents (#31 and #46) identified by the facility as not receiving food prepared in the facility kitchen. The facility census was 76 residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/02/22 with diagnoses including diabetes mellitus (DM), osteomyelitis, hyperlipidemia, and chronic kidney disease (CKD.) Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #19 dated 07/03/23, revealed the resident was cognitively impaired and required supervision and set up help with eating. Review of the Dietary Schedule for 08/12/23, revealed [NAME] #410 and Dietary Aide (DA) #395 were scheduled to work in the kitchen for the breakfast meal on 08/12/23. Review of the time clock records for 08/12/23, revealed [NAME] #410 and DA #395 did not work on 08/12/23. Review of the facility menu dated 08/12/23, revealed it included the following items: choice of juice, oatmeal or cold cereal, pancakes, breakfast sausage links, and choice of milk, coffee, or hot tea. Interview with [NAME] #410 on 08/15/23 at 8:41 A.M., confirmed she was supposed to work on 08/12/23 but had to call off work. [NAME] #410 confirmed she heard there was no one at the facility to cook breakfast on 08/12/23. Interview with Resident #19 on 08/15/23 at 11:00 A.M., confirmed the facility had not served an adequate breakfast on 08/12/23. Resident #19 confirmed they were short-staffed in the kitchen, and they were supposed to have pancakes and sausage links but all he received for breakfast on 08/12/23 was an order of toast. Interview with the Administrator on 08/16/23 at 12:55 P.M., confirmed [NAME] #410 was scheduled to prepare breakfast for the residents on 08/12/23. The Administrator confirmed [NAME] #410 sent her a text message at 11:30 P.M. on 08/11/23 advising she could not be at work on 08/12/23 but the Administrator did not see the text message until 7:30 A.M. on 08/12/23. The Administrator confirmed she arrived at the facility on 08/12/23 at 9:00 A.M. and found Activity Director (AD) #495 had cooked scrambled eggs for some of the residents. Administrator confirmed AD #495 and staff told her the residents had been served toast or cereal per AD #495 and the nursing staff. The Administrator confirmed some of the residents on the B-Hall also received scrambled eggs. The Administrator confirmed the breakfast menu for 08/12/23 listed oatmeal or cereal, pancakes, and sausage links and the residents were not served the items on the menu which was reviewed by the facility registered dietitian (RD) to ensure the resident's nutritional needs were met. Interview with AD #495 on 08/16/23 at 1:00 P.M., confirmed she heard there was no one working in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 7 of 10 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 08/16/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm the dietary department at breakfast time on 08/12/23 so she assisted the nursing staff in passing out toast and cereal to the residents and also made scrambled eggs for some of the residents on the B-Hall. Review of the undated facility policy titled Assistance with Meals revealed the residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Affected - Some This deficiency represents non-compliance investigated under Complaint Numbers OH00144908 and OH00144877. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 8 of 10 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 08/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of facility documents (temperature and sanitation logs), staff interview, and review of facility policy, the facility failed to adequately monitor the water temperature of the dishwashing machine in the kitchen and failed to adequately monitor the sanitizer level for the three-compartment sink in the kitchen. This had the potential to affect all resident residing in the facility with the exception of two residents identified by the facility residents (#31 and #46) who did not receive food prepared in the facility kitchen. The facility census was 76. Findings include: Review of the July 2023 facility dishwashing machine temperature log revealed there were no temperatures recorded during the dinner meals from 07/19/23 through 07/31/23. Observation of the kitchen on 08/15/23 at 11:18 A.M., revealed Laundry Aide (LA) #485 was pulling silverware out of the dishwashing machine and told [NAME] #410 it was ready for the lunch meal. Further observation revealed there were pans drying on the rack next to the three -compartment sink. LA #485 left the kitchen when the Surveyor entered and was not available for an interview. Interview with [NAME] #410 on 08/15/23 at 11:20 A.M., confirmed LA #485 normally worked in the laundry department but he had assisted in the kitchen by washing silverware in the dishwashing machine so it would be available for the lunch meal. [NAME] #410 indicated the kitchen staff should check the water temperatures for the dishwashing machine at each meal and the wash temperature should be at least 150 degrees (Fahrenheit) and the rinse temperature should be at least 180 degrees F. [NAME] #410 further confirmed the dishwasher was a high temperature machine and the temperatures should be recorded on the facility's temperature log. [NAME] #410 confirmed the kitchen staff should check the sanitizer level of the three-compartment sink at each meal and record the information on the sanitizer log. [NAME] #410 confirmed the sanitizer level should measure 150 to 200 parts per million (ppm.) [NAME] #410 confirmed the dishwashing machine temperature log had not been completed for the dinner meals from 07/19/23 through 07/31/23 and for August 2023 there were no temperatures recorded for dinner from 08/01/23 through 08/15/23. There were no temperatures recorded for breakfast, lunch, and dinner from 08/11/23 through 08/15/23. [NAME] #410 confirmed the sanitizer log for the three-compartment sink for August 2023 had not recorded sanitizer levels for breakfast, lunch, and dinner from 08/07/23 through 08/15/23. Interview with the Administrator on 08/16/23 at 12:55 P.M., confirmed the dishwashing machine temperature log had not been completed for the dinner meals from 07/19/23 through 07/31/23 and for August 2023 there were no temperatures recorded for dinner from 08/01/23 through 08/15/23. There were no temperatures recorded for breakfast, lunch, and dinner from 08/11/23 through 08/15/23. The Administrator confirmed the sanitizer log for the three-compartment sink for August 2023 had not recorded sanitizer levels for breakfast, lunch, and dinner from 08/07/23 through 08/15/23. Interview with the Administrator further confirmed the water temperature levels and sanitizer levels should be recorded with every meal as a food safety/sanitation measure and corrective action should be taken if required levels were not met. Review of the August 2023 facility dishwashing machine temperature log revealed there were no temperatures recorded during the dinner meal from 08/01/23 through 08/15/23. There were no dishwasher temperatures recorded for breakfast, lunch, and dinner meals from 08/11/23 through 08/15/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 9 of 10 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 08/16/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the for August 2023 sanitizer log for the three-compartment sink revealed there were no recorded sanitizer levels for breakfast, lunch, and dinner meals from 08/07/23 through 08/15/23. Review of the facility policy titled Dishwashing Machine Use revealed the facility dishwashing machine should have a water temperature of at least 150 degrees F for the wash cycle and at least 180 degrees F for the rinse cycle. The sanitizer level for the three-compartment sink should measure 150 to 200 ppm. The water temperature levels, and sanitizer levels should be checked for each meal and recorded in the temperature log. The kitchen staff will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The staff will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. Corrective action will be taken immediately if sanitizer concentrations are too low. This deficiency represents non-compliance investigated under Complaint Number OH00144908. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 10 of 10