Inspection·October 3, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the current physician orders dated 09/27/19 for Resident #224 revealed an order to use privacy bag for the resident's catheter bag. Observation and interview on 10/01/19 at 8:41 A.M. revealed Resident #224 being assisted with his breakfast by State Tested Nurse Aide (STNA) #201. The resident's catheter bag was hanging on the right side of the bed and did not have a privacy bag. Interview with STNA #201 verified Resident #224 did not have a privacy bag and they should of put one on when he was admitted . Observation and interview on 10/03/19 at 8:32 A.M. revealed Resident #224's catheter bag was not covered with a privacy bag. Interview with STNA #202 verified Resident #224's catheter bag was uncovered and should be covered with a privacy bag. Review of the facility policy titled, Resident Rights revised October 2004 revealed residents had the right to be treated with dignity and respect. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 If continuation sheet Page 2 of 5 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowling Green Manor 1021 W Poe Rd Bowling Green, OH 43402 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident at risk for constipation had regular bowel movements. This affected one resident (#19) of one reviewed for constipation. The facility census was 81. Residents Affected - Few Findings include: Review of Resident #19's medical record revealed an admission date of 04/09/19. Diagnoses included heart failure, personal history of breast cancer, and depressive disorder. Review of Resident #19's physician's orders revealed active orders dated 04/09/19 for Biscolax Suppository 10 mg (milligrams) insert one application rectally as needed (PRN) for constipation, Senna Plus table 8.6-50 mg, one tablet PRN for constipation one to four tablets daily, and for Glycolax Powder give one dose PRN daily for constipation. Review of physician order dated 04/15/19 revealed an order for Sennosides - Docusate Sodium tablet 8.6-50 mg, one tablet, twice a day for constipation. Review of Resident #19's care plan revised 07/18/19 revealed supports and interventions for risk for constipation related to opioid medications and decreased mobility. Interventions for constipation included to administer Senna plus and Sennosides - Docusate as ordered, assess bowel sounds, and monitor resident for bowel movements. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of Resident #19's State Tested Nursing Assistant (STNA) tracking for the last 30 days revealed Resident #19 went five days from 09/18/19 to 09/22/19 without a bowel movement. Resident #19 then went six days from 09/26/19 to 10/01/19 without a bowel movement. Review of Resident #19's Medication Administration Record (MAR) for the months of September and October 2019 revealed Resident #19 received Sennosides-Docusate Sodium Tablet 8.6-50 mg daily as ordered. Resident #19 received PRN Senna Plus tablet and PRN GlycoLax Power on 09/04/19. Administration effectiveness was noted as unknown. Resident #19 was provided PRN Biscolax Suppository 10 mg on 10/01/19 and administration effectiveness was noted as ineffective. No other interventions were noted as being administered for the time frames of 09/18/19 to 09/22/19 and 09/26/19 to 10/01/19 when Resident #19 went without a bowel movement. Interview on 10/01/19 at 9:18 A.M. with Resident #19 revealed she had not had a bowel movement in six days. Resident #19 stated she told the staff about it and she was not aware of anything they had done to help. Resident #19 reported no pain or discomfort at the time. Interview on 10/01/19 at 10:10 A.M. with STNA #201 confirmed Resident #19's bowel tracking revealed the resident had not had a bowel movement in six days. STNA #201 reported notifications were provided to the nursing staff regarding lack of bowel movements through the electronic tracking system. STNA #201 reported not being aware of how long a resident would go before an alert was triggered, however reported knowledge of suppositories being used for Resident #19 if she went too long. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 If continuation sheet Page 3 of 5 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowling Green Manor 1021 W Poe Rd Bowling Green, OH 43402 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 on 10/03/19 at 10:42 A.M. with Corporate Nurse #380 revealed there was no written bowel protocol or procedures for constipation. 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: 365333 If continuation sheet Page 4 of 5 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bowling Green Manor 1021 W Poe Rd Bowling Green, OH 43402 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This had the potential to affect all 81 residents who received food from the kitchen. Findings include: Observation on 09/30/19 at 9:36 A.M. of the dry storage room revealed an open, partially used gallon of soy sauce on the dry storage shelf. The label revealed to refrigerate after opening. Interview at the time of the observation with Dietary Manager (DM) verified the soy sauce was not refrigerated and the label indicated to do so after opening. Observation on 09/30/19 at 9:40 A.M. of the walk in cooler revealed an opened, uncovered, undated, unlabeled bag of hard boiled eggs on a shelf. Six eggs were observed in the open bag. Interview at the time of the observation with DM #300 verified the eggs were opened, uncovered, and undated. Review of the facility policy titled, Dry Storage, revised January 2018 revealed the facility was to protect food from contamination and spoilage. Stock was to be dated with the month day and year on the arrival and older stock was to be used first. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 If continuation sheet Page 5 of 5