Inspection·October 23, 2024

F 0812 leaking DM #195 stated the kitchen was in need of a deep cleaning. Level of Harm - Minimal harm or potential for actual harm Interview with Maintenance Supervisor (MS) #106 on 10/23/24 at 1:05 P.M. revealed the three-compartment sink was leaking a few weeks ago but he repaired it. MD #106 indicated he was not aware it was leaking again. MS #106 stated the black substance across the kitchen appeared to be mold. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 2 of 4 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 10/23/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a clean and sanitary environment. This affected three (#10, #59, and #63) of the three residents reviewed. The facility census was 87. Findings include: 1) Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, insomnia, diabetes mellitus (DM), obstructive sleep apnea, essential primary hypertension, anxiety disorder, chronic kidney disease, and hyperlipidemia. Review of the Minimum Data Set (MDS) assessment, for Resident #10, dated 08/09/24, revealed Resident #10 was cognitively intact. Interview with Resident #10 on 10/23/24 at 12:21 P.M., revealed the floors were so dirty in her room, she attempted to clean them herself with a cloth and soap. Observation of the resident's room at the same time revealed two large peeling black non-skid strips in front of Resident #10's bed. The floor in the resident's room and bathroom were very sticky. The bathroom walls were stained with brown splatter stains running down the walls. The floor in Resident #10's bathroom was lifted up around the toilet and the floor was soiled. Resident #10's toilet was soiled and heavily stained with an unknown brown substance. Interview with Licensed Practical Nurse (LPN) #161 on 10/23/24 at 12:23 P.M. verified the condition of the resident's room. LPN #161 stated the black strips on the floor were from a previous Resident's fall interventions. 2) Review of the medical record for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, neurocognitive disorder with Lewy bodies, diabetes mellitus, history of Coronavirus 2019 (COVID-19), insomnia, edema, and major depressant disorder. Review of the MDS assessment, dated 10/01/24, revealed Resident #59 had impaired cognition. Observation of Resident #59's room on 10/23/24 at 12:14 P.M. with Housekeeping Director (HD) #179 revealed the resident's floor was sticky and soiled with a brown and black stain all around the walls. There was a bed frame with no mattress and missing a wheel which made the bed tilt to one side. There were two concrete bricks stacked next to the broken wheel on the floor. HD #179 verified the condition of the resident's room and the broken bed in the resident's room. HD #179 stated the two bricks stacked next to the bed was an attempt to fix the bed by maintenance staff. HD #179 stated the broken bed, and bricks were safety hazards for a memory care unit. Interview with Maintenance Supervisor (MS) #106 on 10/23/24 at 1:05 P.M., verified the broken bed frame and bricks located in Resident #59's room. MS #106 verified the concrete blocks lying on the floor next to the broken bed was an attempt to repair the broken bed frame. 3) Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses included ataxia, major depressant disorder, osteoarthritis, dementia, anxiety, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 3 of 4 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 10/23/2024 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 0921 Alzheimer's disease, kidney disease, and anxiety. The resident received Hospice services. Level of Harm - Minimal harm or potential for actual harm Review of the MDS assessment, dated 09/03/24, revealed Resident #63 had severely impaired cognition. Residents Affected - Few Observation of Resident #63's room on 10/23/24 at 12:11 P.M. with HD #179 revealed the cove base was hanging from the wall and the base of the wall had black spots throughout the resident's room. The floor was sticky and soiled, and a white towel stained with an unknown yellow substance which was pushed up against the television plug. HD #179 stated the towel was soaked with urine and the floor was sticky related to the resident's urine. Review of the facility policy titled, Quality of Life-Homelike Environment, dated May 2017, revealed the facility will provide residents with a clean, safe, and homelike environment. This includes a clean, safe, and orderly environment. This deficiency represents non-compliance investigated under Complaint Number OH00158493. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366175 If continuation sheet Page 4 of 4