Inspection·September 1, 2022

F 0561 Level of Harm - Minimal harm or potential for actual harm would serve food to residents in dining room and room trays using meal tickets by the Nutrition Services Personnel. Nutrition Services Assistant would deliver meals by cart and room tray list would be provided to Nutrition Services prior to meal service. All residents were encouraged to eat their meals in the dining room and if a resident remained in their room, nursing was to give Nutrition Services a room service list 30 minutes prior to the start of meal service. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 2 of 7 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected four (#18, #22, #41, and #45) of 14 residents reviewed for accuracy of the MDS assessment. The census was 44. Residents Affected - Some Findings include: 1. Review of the medical record of Resident #18 revealed an admission date of 12/22/20. Diagnoses include lumbosacral spinal stenosis, anxiety disorder and unspecified visual disturbance. Review of the quarterly MDS assessments dated 06/10/22 and 07/15/22 revealed no brief interview of mental status (BIMS) nor mood assessment being completed as required. Interview on 09/01/22 at 8:57 A.M. with Director of Clinical Support #174 provided verification of the MDS assessment incompleteness. 2. Review of Medical Record for Resident #22 admitted [DATE] with diagnoses that included, but are not limited to, depression, chronic pain, spinal stenosis, mild cognitive impairment, delusional disorders, anxiety, and brief psychotic disorder. Review of Quarterly MDS dated [DATE] revealed no BIMS or mood assessment being completed. Interview on 09/01/22 at 8:57 A.M. with Director of Clinical Support #174 provided verification of the MDS assessment incompleteness. 3. Review of Medical Record for Resident #41 admitted [DATE] with diagnoses that included, but are not limited to, noncompliance with other medical treatment and regimen, type two diabetes, morbid obesity, pressure ulcer stage four (deep wound that reaches the muscles, ligaments, or bone) sacral region, depression, insomnia, and renal dialysis. Review of Minimum Data Set (MDS) dated [DATE] for Resident #41 revealed resident was coded for no unhealed pressure ulcers. Records indicated resident had a stage four pressure ulcer to sacral area. Interview on 08/31/22 at 10:12 A.M. with RN #166 verified the MDS was incorrect for Resident #41. MDS #166 verified Resident #41 had a stage four pressure wound. 4. Review of the medical record for Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses included, but not limited to, diabetes mellitus type two, osteoarthritis, depression, chronic gout, and hypertension. Review of a progress notes dated 07/17/22 at 4:41 P.M. revealed Resident #45 was transferred to the hospital for a change of condition. Review of a discharge return not anticipated MDS assessment target date 07/17/22, revealed Resident #45 had an unplanned discharged to community. Interview on 08/30/22 at 2:59 P.M. with RN #166 verified the discharge MDS dated [DATE] for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 3 of 7 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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 0641 Resident #45 was not accurate. The RN verified the resident was not discharged to the community. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 4 of 7 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure treatments were completed as ordered. This affected one (Resident #41) of two residents reviewed for wounds. The census was 44. Residents Affected - Few Findings include: Review of Medical Record for Resident #41 admitted [DATE] with diagnoses that included, but not limited to, pressure ulcer stage four (deep wound that reaches the muscles, ligaments, or bone) in sacral region, noncompliance with other medical treatment and regimen, type two diabetes, morbid obesity, depression, insomnia, and renal dialysis. Review of Minimum Data Set (MDS) dated [DATE] for Resident #41 revealed resident is cognitively intact. Resident #41 required extensive assist of two for Activities of Daily Living (ADL's) and had a catheter and colostomy. MDS indicated Resident #41 did not have any unhealed pressure ulcers. Review of pharmacy delivery sheet revealed Acetic Acid 0.25 percent (%) solution (1000 milliliters) was delivered on 07/09/22, 07/23/22, 08/02/22, and 08/23/22. Review of Skin/Wound note dated 07/25/22 at 7:08 A.M. for Resident #41 revealed dressing changed to coccyx/sacral area. Previous dressing had red/tan and green drainage. Dressing was soaked with blood. Wound bed was beefy red in color with slight macerations to surrounding areas. Skin around wound was red and bleeding. Wound was cleansed with normal saline and wet to dry dressing soaked in normal saline due to being out of regular solution. Wound was covered with three abdominal pads, covered with a blue brief, and secured with tape. Review of Skin/Wound note dated 08/19/22 at 2:51 A.M. for Resident #41 revealed dressing changed to coccyx/sacral area. Previous dressing had red/tan and green drainage. Dressing was soaked with blood. Wound bed was beefy red in color with slight macerations to surrounding areas. Wound had a strong odor. Skin around wound was red and bleeding. Wound was cleansed with normal saline and wet to dry dressing soaked in normal saline due to being out of regular solution. Wound was covered with three abdominal pads, covered with a blue brief and secured with tape. Review of Medication Administration Record (MAR) for Resident #41 revealed treatment was not completed on 08/27/22 on the 7:00 A.M. to 7:00 P.M. shift. Interview on 08/31/22 at 3:44 P.M. with Clinical Educational Specialist (CES #179) verified treatment for Resident #41 was not completed on 08/27/22. CES #179 verified that treatment was not completed per the physician order on 07/25/22, 08/19/22, and 08/22/22. Review of August 2022 physician orders revealed Resident #41 had an order for wound treatment that consisted of cleanse/irrigate coccyx/sacral wound with Acetic Acid 0.25 percent strength solution twice daily. Staff to pack wound with wet to dry kerlix and cover with abdominal pads, dry dressings and secured with medipore tape. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 5 of 7 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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 medical record review, observations and staff interview, the facility failed to maintain a safe environment when medications were left unattended by staff. This directly affected one resident (#31) and had the possibility to affect seven residents (#2, #3, #13, #34, #36, #39, and #43) identified by the facility as being independently mobile and cognitively impaired, residing in the D hall. The facility census was 44. Findings include: Review of the medical record of Resident #31 revealed an admission date of 11/22/20. Diagnoses include atherosclerotic heart disease of native coronary artery with other forms of angina pectoris, chronic atrial fibrillation, hypertensive heart disease with heart failure, acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, presence of cardiac pacemaker, history of alcohol dependence, uninhibited neuropathic bladder, gastro-esophageal reflux disease, benign prostatic hyperplasia with lower urinary tract symptoms, feeling of incomplete bladder emptying, and presence of urogenital implants. Review of the quarterly minimum data set assessment dated [DATE] revealed he had moderate cognition deficit and required supervision with set-up help only with eating. Observation on 08/29/22 at 10:41 A.M. revealed a small plastic cup with seven medication tablets and or caplets, sitting on the bed of Resident #31. He stated I will take those when I get my Ensure. An interview with Registered Nurse (RN) #178 verified the caplets and tablets were left at his bedside and included aspirin 81 milligrams (mg), folic acid one mg, omeprazole 10 mg, apixaban 75 mg, docusate 100 mg caplet, metoprolol 25 mg, and oxybutynin five mg. RN #178 then proceeded to begin to exit the room, leaving the medications and the surveyor further asked about the medications being left at the bedside. Resident #31 stated yesterday they gave me a Boost to take these with. RN #178 took the medications to the cart and obtained a boost drink and returned and Resident #31 took the medications without difficulty. The facility identified seven residents (#2, #3, #13, #34, #36, #39, and #43) who are independently mobile and cognitively impaired, that reside on the D hall and that could potentially access the unattended/unsecured medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 6 of 7 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 365238 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wapakoneta Manor 1010 Lincoln Ave Wapakoneta, OH 45895 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to post daily nurse staffing information. This affected 44 residents who reside in the facility. The census was 44. Residents Affected - Many Findings include: Observation on 08/30/22 at 7:28 A.M. of daily staffing tool at entryway revealed a date of 08/23/22. Interview on 08/30/22 at 7:30 A.M. with Corporate Director of Clinical Services (CODC) #174 verified staffing tool was dated 08/23/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365238 If continuation sheet Page 7 of 7