Inspection·September 29, 2022

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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, observations, resident and staff interviews and policy review, the facility failed to accurately monitor fluid intake for a resident receiving dialysis services. This affected one (#385) of one residents reviewed for dialysis. The facility census was 82. Residents Affected - Few Findings include: Review of Resident #385's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included arthritis, hypertension, diabetes mellitus, type II, end stage renal disease with dependence on renal dialysis, anemia, hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #385 was cognitively intact, required extensive assistance for bed mobility, transfers, locomotion, and toilet use. Resident #385 required limited assistance needed with personal hygiene, dressing and walking. Resident #385 required total dependence for bathing with one-person physical assist. Resident #385 received renal dialysis three times a week on Monday, Wednesday, and Thursday. Review of physician orders revealed an ordered dated 09/15/22 for a renal diabetic diet with a 1,000 milliliter (ml) fluid restriction per twenty-four hours, 100 ml per shift for nursing and 700 ml per shift for dietary. An additional order written on 09/16/22 for a 1,000 ml fluid restriction per 24 hours, 100 ml per shift for nursing and 700 ml a day for dietary. Renal dialysis order written on 09/26/22 stated encourage resident to go for scheduled dialysis appointments on Monday, Wednesday, and Thursday. Review of the care plan dated 09/16/22 revealed Resident #385 had a potential for fluid overload. Interventions included medications administered as ordered, diet as ordered, a fluid restriction, vital signs monitored, and document intake and output each shift and for a daily weight to be completed at the same time each day. Review of the daily fluid consumed by mouth for Resident #385 from 09/16/22 to 09/28/22 revealed the following: On 09/16/22 the total fluid consumed was 360 ml. On 09/17/22 the total fluid consumed was 360 ml. On 09/18/22 the total fluid consumed was 840 ml. On 09/19/22 the total fluid consumed was 720 ml. On 09/20/22 the total fluid consumed was 360 ml. On 09/21/22 the total fluid consumed was 360 ml. On 09/22/22 the total fluid consumed was 420 ml. On 09/23/22 the total fluid consumed was 440 ml. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 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 0698 On 09/24/22 the total fluid consumed was 820 ml. Level of Harm - Minimal harm or potential for actual harm On 09/25/22 the total fluid consumed was 600 ml. On 09/26/22 the total fluid consumed was 760 ml. Residents Affected - Few On 09/27/22 the total fluid consumed was 470 ml. On 09/28/22 the total fluid consumed was 660 ml. Review of the September treatment record for Resident #385 revealed the following fluid outputs each day. On 09/16/22 the total fluid intake was 850 ml. On 09/17/22 the total fluid intake was 730 ml. On 09/18/22 the total fluid intake was 750 ml. On 09/19/22 the total fluid intake was 1,020 ml. On 09/20/22 the total fluid intake was 520 ml. On 09/21/22 the total fluid intake was 660 ml. On 09/22/22 the total fluid intake was 600 ml. On 09/23/22 the total fluid intake was 470 ml. On 09/24/22 the total fluid intake was 810 ml. On 09/25/22 the total fluid intake was 790 ml. On 09/26/22 the total fluid intake was 1060 ml. On 09/27/22 the total fluid intake was 790 ml. On 09/28/22 the total fluid intake was 820 ml. Review of the recording of fluid intake for Resident #385 found the facility had not accurately monitored fluid intake. Resident #385 exceeded the 1,000 ml fluid restriction as ordered on 09/19/22 and 09/26/22. Additionally, the intake recorded on the fluid consumed task was more than the twenty-four-hour total recorded on the treatment record on 09/18/22 and 09/24/22. Observation on 09/28/22 at 3:05 P.M. of State Tested Nursing Assistant (STNA) #602 filled the gray lidded pitcher at the bedside of Resident #385 with ice. Interview with STNA #602 at the time of the observation verified Resident #385 had a lidded gray pitcher that was filled with ice at bedside. Interview with the Director of Nursing (DON) on 09/28/22 at 5:14 P.M. verified Resident #385 was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 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 0698 a fluid restriction. The DON was unaware of a gray lidded pitcher at the bedside of Resident #385. Level of Harm - Minimal harm or potential for actual harm Observation on 09/29/22 at 9:10 A.M. revealed no gray lidded pitcher at the bedside of Resident #385. Interview at the time of the observation with Resident #385 verified the gray lidded pitcher had been removed by the staff. Residents Affected - Few An additional interview on 09/29/22 at 9:13 A.M. with STNA #602 verified the gray water pitcher should not have been at the bedside of Resident #385. STNA #602 further verified she was unaware of what the fluid amount would be when the gray pitcher was filled with ice. Interview on 09/28/22 at 5:20 P.M. with the DON revealed the fluid documentation on the fluid consumed task is completed by the nursing assistants and included the fluids provided for meals. The fluids provided by the nurses with medication administration is added to what is reported by the nursing assistants and documented on the treatment record. The DON verified the fluid restriction was not followed as ordered on 09/19/22 and 09/26/22 and further verified the intake recorded on the fluid consumed task was more than the twenty-four-hour total recorded on 09/18/22 and 09/24/22. Additional interview with the DON on 09/29/22 at 7:54 A.M. verified the facility is not accurately recording the fluid intake for Resident #385. Review of the facility policy titled Fluid Restrictions dated February 2017 revealed residents on fluid restricted diets will receive the prescribed amount of fluids per day on order to manage a medical condition related to fluid balance or to meet their specific needs. Review of facility policy titled Instructions Food and Fluid Acceptance titled June 2016 revealed food and fluid acceptance will be recorded at each meal and input will be documented in the electronic documentation system. The recording of fluids at each meal are recorded as fluid milliliters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 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 0791 Provide or obtain dental services for each resident. 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, observation, resident and staff interview and review of facility policy, the facility failed to ensure dental services were provided timely for residents with dental concerns. This affected one (#76) of one residents reviewed for dental services. The facility census was 82. Residents Affected - Few Findings Include: Review of Resident #76's medical record revealed an admission date of 07/01/20. Diagnoses included hemiplegia, pseudobulbar affect, dysphagia, type II diabetes, major depressive disorder, anxiety disorder, peripheral vascular disease, and psychosis. Review of Resident #76's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating Resident #76 was moderately cognitively impaired. Resident #76 required extensive assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene including brushing teeth. Resident #76 displayed no behaviors during the review period. Resident #76 was noted to have mouth or facial pain, discomfort, or difficulty with chewing at the time of the review. Resident #76 received scheduled pain medications at the time of the review. Resident #76 reported pain almost constantly and the pain made it hard for her to sleep at night and limited her day to day activities. Resident #76 rated her pain at an eight on a scale of one to ten. Review of Resident #76's care plan revised 09/20/22 revealed supports and interventions for potential for pain and poor dental health. Interventions for dental health included coordinating arrangements for dental care, transportation as needed/as ordered, inspect oral cavity twice daily and report changes to the nurse including broken teeth, bleeding, swollen gums or discomfort with oral care, monitor, document and report signs and or symptoms of oral/dental problems needing attending and provide mouth care as per activities of daily living (ADL) personal care hygiene. Review of Resident #76's Dental Services information revealed on 03/18/21 Resident #76 was seen by the dentist and it was noted extractions were proposed. On 06/17/21 it was noted the dentist was waiting for approval for extractions. On 09/24/21 it was noted Resident #76 had broken and decayed teeth. At the time Resident #76 was cooperative with care, asymptomatic, and they were waiting for prior authorization for extractions to be done. On 06/09/22 it was noted Resident #76 was seen by the dentist and he spoke with Resident #76's daughter about the treatment plan. The dentist advised full upper and lower dentures if the insurance refused the partials. Resident #76 had no reported pain or discomfort at the time. On 07/15/22 Resident #76 was seen again by the dentist. Resident #76 reported her teeth hurt her at times. They were still awaiting prior authorization. Resident #76 had gone from 03/18/21 to 09/28/22 without having her dental concerns addressed or her recommended extractions completed. In addition, Resident #76 went from 07/15/22 to 09/28/22, 75 days, without dental treatment following reported pain. Interview on 09/27/22 at 2:38 P.M. with State Tested Nursing Assistant (STNA) #561 revealed Resident #76 was able to make her needs known and was cooperative with care. STNA #561 reported Resident #76 has broken and decaying teeth which had been causing Resident #76 pain. STNA #561 reported at times Resident #76 would be resistant to brushing her teeth because of the oral pain. STNA #561 stated she had reported the oral pain to the nurse but she was not aware if the dentist was in to see Resident #76 or if anything was being done to help Resident #76 with her mouth pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 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 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/28/22 at 8:51 A.M. with Resident #76 revealed she had mouth pain that got in the way of her wanting to brush her teeth and sometimes got in the way of her eating. Resident #76 reported her mouth hurt, pointing to her top front teeth indicating what part of her mouth hurt. Resident #76 reported the dentist saw her but hasn't done anything to help her with her teeth. Coinciding observation of Resident #76's teeth found her front top teeth were broken and discolored. Resident #76 repeated her top teeth hurt her. Interview on 09/28/22 at 1:38 P.M. with Corporate Nurse (CN) #625 reviewed the timeline of Resident #76 dental services. CN #625 verified in March of 2021 Resident #76 was seen by the dentist and extractions were recommended with a partial lower and partial upper plate. CN #625 stated the dentist would not do the extractions until the plates were authorized. In June of 2021 the dentist was still waiting on approval. On 07/06/21 and again on 01/28/22 the partial was denied by Resident #76's insurance. Then on 06/09/22 the timeline revealed the dentist spoke with Resident #76's daughter about the treatment plan. The dentist advised to reattempt treatment plan of partial lower and partial upper. If Resident #76's insurance refused, then the recommendation was for a full upper and full lower. Resident #76 had no pain or discomfort at the time. On 07/15/22 Resident #76 was seen again. The dental note indicated Resident #76 reported her teeth were hurting. At the time they were continuing to wait for prior authorization. CN #625 reported Resident #76's next dental appointment was scheduled 11/01/22 and she may have been approved for her dentures so her extractions may be able to be completed. CN #625 stated the Director of Nursing (DON) would have more information. Interview on 09/28/22 at 2:13 P.M. with the DON verified Resident #76 had intermittent dental pain and the pain was managed with her scheduled and as need (PRN) pain medications. She verified Resident #76 at times needed assistance with oral hygiene as she would refuse. The DON stated it was not known if the refusals were from dental pain or something else. The DON reported Resident #76 was seen by the dentist and had been waiting for insurance approval to have her teeth extracted. The DON reported the managed care insurance provider case manager was difficult to work with and she had a call out to her to check on status of her approval so Resident #76 could have her teeth extracted. Interview on 09/28/22 at 2:28 P.M. with the DON revealed an insurance approval was received and while waiting for extractions to be completed a request was put in today for an oral topical paste to aide in oral pain and provision of care. Review of the approval notice titled, Medicaid Denture Prior Authorization, received by the facility on 09/28/22 revealed Resident #76 was approved for an upper denture to improve chewing function with necessary extractions on 09/06/22. Interview on 09/28/22 at 2:50 P.M. with Residential Service Coordinator (RSC) #502 and the DON revealed regular case conferences were held and included discussion of Resident #76's dental status. An approval for Resident #76's dentures was received today 09/28/22 so they could move forward with her tooth extractions. Resident #76's next dental appointment was scheduled for 11/01/22 and they had her on the list for any cancellations. The DON reported they had already gotten the order for the topical oral pain medication and it was going to be used prior to oral care until her upper tooth concerns were addressed. The facility had not followed up with the prior authorization request until 09/28/22 and learned on 09/28/22 of the 09/06/22 approval. Review of the facility policy titled, Dental Services, revised 05/09/22 revealed the facility would assist residents in obtaining routine and twenty four hour emergency dental care. Emergency dental services included services needed to treat episodes of acute pain of teeth, gums or palate, broken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365333 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 365333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2022 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 0791 or otherwise damaged teeth or any other problems of the oral cavity. 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 7 of 7