Health inspection·October 18, 2018

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician was notified of a seven pound weight gain in a week per orders. This affected one (#72) of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of Resident #72's medical record revealed an admission date of 08/06/18, with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and hypertension (high blood pressure). Review of the admission minimum data set (MDS) assessment dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 14. Review of the physician's order dated 09/11/18 revealed an order for a weekly weight and to notify the physician if a five pound weight increase was noted over a one week period. Review of Resident #72's weights revealed her weight on 09/19/18 was 271 and on 09/26/18 her weight was 278. Review of the progress notes from 09/19/18-09/27/18 revealed no indication the physician was notified regarding the weight gain of greater than five pounds. Interview with Licensed Practical Nurse (LPN) #400 on 10/17/18 at 3:32 P.M., confirmed Resident #72 had an order for the physician to be notified if there is a weight gain of five pounds in one week. LPN #400 confirmed there was no evidence the physician was notified when Resident #72 had a seven pound weight gain in one week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 2 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, skilled nursing protection notification review, staff interview and review of policy and procedures, the facility failed to provide skilled nursing facility (SNF) advance beneficiary notices (ABN) to residents as required. This affected two (#58 and #72) of two residents reviewed for receiving appropriate ABN who remained in the facility after being cut from Medicare part A services. The facility census was 77. Residents Affected - Few Findings include: 1) Review of medical record for Resident #58 revealed and admission date of 08/29/18, with diagnoses including fracture of the right neck femur, hypertension, overactive bladder, major depressive disorder, muscle weakness and constipation. Review of skilled beneficiary protection notification review for Resident #58 revealed she started Medicare part A service on 08/29/18 and her last covered day was 10/13/18 due to Resident #58 meeting her max potential. She was issued her last cover day notice called notice of Notice of Medicare Non-coverage on 10/10/18. Further review documented the resident remained in the facility and never received a SNF ABN as required by Medicare notifying her of the cost to remain in the facility and the right to request a demand bill to continue therapy if she so desired. 2) Review of medical record for Resident #72 revealed an admission date of 08/06/18, with diagnoses including confusional arousal, muscle weakness, anemia, left leg below the knee amputee, type two diabetes, hypertension and shortness of breath. Review of skilled beneficiary protection notification review for Resident #72 revealed she started Medicare part A service on 08/06/18 and her last covered day was 10/05/18 due to Resident #72 meeting her max potential. She was issued her last cover day notice called notice of Notice of Medicare Non-coverage on 10/03/18. Further review documented the resident remained in the facility and never received a SNF ABN as required by Medicare notifying her of the cost to remain in the facility and the right to request a demand bill to continue therapy if she so desired. Interview on 10/17/18 at 12:20 P.M., with Case Manager Registered Nurse #500 verified she did not provide Resident #58 and Resident #72 with a Skilled Nursing Facility Advanced Beneficiary Notice as required. She stated after review of the form she should have gave this notice to them when it was determined they were staying in the facility long term. Review of undated policy titled SNF-beneficiary notice requirements documented the facility is to provide the resident in writing the financially liability and the option for appeal rights if they want to continue therapy while a demand bill is submitted the Medicare for review. This is for residents who decide stay long term and were cut from Medicare part A services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 3 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 medical record review and staff interview, the facility failed ensure minimum data set (MDS) assessments were code accurately based upon the resident assessment information. This effected three (#15,#30, and #77) of 21 resident's MDS assessments reviewed. The facility census was 77. Residents Affected - Some Findings include: 1.) Review of medical record for Resident #30 revealed an admission date of 05/29/18, with diagnoses including dementia with behavioral disturbances, hypertension, major depression, overactive bladder, polyarthritis, altered mental status, constipation, insomnia, weakness and anxiety disorder. Review of Hospital record dated 07/01/18, documented the resident was admitted to the hospital on [DATE]. Resident #30 was found to have a urinary tract infection (UTI) with extended spectrum beta-lactamase (ESBL) which is a multi-drug resistant organism (MDRO). She was then started on Augmentin 875/125 milligrams twice a day by mouth for 10 days. Review of nursing note dated 07/06/18, documented the resident was readmitted to the facility on [DATE] with orders to continue antibiotic Augmentin 875/125 milligrams twice a day by mouth for a remainder of eight days for a UTI. Review of review of quarterly MDS, with an assessment reference date of 08/03/18, for Resident #30 lacked documentation of her being assessed as having a (UTI) in the last 30 days. Interview on 10/16/18 at 2:32 P.M., with MDS Nurse #320 verified the MDS was coded in error and should have reflected Resident #30's UTI. She stated she would complete a correction of that assessment. 2.) Review of Resident #15's medical record revealed an admission date of 02/05/17, with diagnoses of congestive heart failure, anxiety disorder, and type two diabetes mellitus. Review of the significant change MDS assessment dated [DATE], identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. The MDS failed to identify the resident was receiving hospice services. Review of the physician's orders revealed an order dated 07/06/18, to admit to local Hospice services for congestive heart failure. Interview with MDS nurse #320 on 10/17/18 at 4:32 P.M., confirmed the significant change MDS was coded inaccuracy and did not reflect the resident receiving hospice services. 3.) Review of the medical record for Resident #77 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, dependence on renal dialysis, type two diabetes mellitus, protein calorie malnutrition, atrial fibrillation, hypertension, visual loss, and peripheral vascular disease. Review of a care plan revision date 10/11/18, revealed Resident #77 needed hemodialysis related to end stage renal disease. Review of the physician order dated 10/08/18, revealed the resident was to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 4 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 receive hemodialysis at a local dialysis center every Monday, Wednesday, and Friday. Level of Harm - Minimal harm or potential for actual harm Review of the five day MDS assessment dated [DATE], revealed no assessment of resident receiving dialysis. Residents Affected - Some Interview on 10/17/18 at 3:21 P.M., MDS nurse #320 revealed Resident #77 received dialysis three times a week. MDS nurse #320 verified the five day MDS assessment dated [DATE] for Resident #77 was not accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 5 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan was initiated for the use of a diuretic. This affected one (#72) of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of Resident #72's medical record revealed an admission date of 08/06/18, with diagnoses of chronic obstructive pulmonary disease, shortness of breath, and hypertension (high blood pressure). Review of the admission minimum data set (MDS) assessment dated [DATE], identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 14. The assessment identified the resident as receiving a diuretic (water pill) seven out of the seven day look back period. Review of Resident #72's physician's orders revealed the resident was receiving Bumex (diuretic) 3 milligrams two times a day. On 10/15/18, the ordered Bumex was changed to 3 mg three times a day. Review of Resident #72's care plan's failed to reveal a care plan was initiated for the use of a diuretic. Interview with Registered Nurse (RN) #320 on 10/17/18 at 3:18 P.M.,confirmed there was no care plan for the use of a diuretic and there should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 6 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and staff interview, the facility failed to provide resident who was unable to carry out activities of daily living with the necessary services to maintain good grooming. This affected one (#9) of one resident reviewed for the provision of activities of daily living. The total facility census was 77. Residents Affected - Few Findings included: Medical record review for Resident #9 revealed an admission date of 06/30/16, with diagnoses: chronic kidney disease Stage 4, dysphagia, major depressive disorder, symbolic dysfunctions, muscle weakness, mild cognitive impairment, adjustment disorder with depressed mood, atrial fibrillation, hypokalemia, insomnia, presence of cardiac pacemaker, sick sinus syndrome, syncope and collapse. Observation on 10/15/18 at 11:24 A.M., in the dining room, Resident #9 had unshaven facial hair that appeared to be more than one day's growth. State Tested Nurse Aide (STNA) #318 stated at that time, that Resident #9 was unable to shave himself. Observation on 10/16/18 at 07:10 AM, revealed Resident #9 was observed to be up and dressed, eating breakfast in the dining room, still unshaven. Observation on 10/16/18 at 12:26 PM, Resident #9 was observed to be unshaven. STNA #316 was asked by surveyor if the resident was combative or uncooperative with activities of daily living and she replied No, he always cooperates. Resident #9 stated I can't shave myself. STNA #316 stated she would assist the resident at that time. She verified that she had not completed his care that morning, and he had not been shaved for several days. Review of the annual minimum data set (MDS) assessment of 07/04/18, noted the resident was cognitively impaired. The assessment reflected the resident required the extensive assist of one staff to complete personal hygiene tasks, including the task of shaving. Review of the care plan for Resident #9 documented the resident with an activities of daily living (ADL) self care performance deficit with a goal which stated resident would be clean and well groomed daily. Planned interventions included 1-2 staff assist to participate with personal hygiene, including shaving. The facility had no policy to address daily shaving of male residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 7 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview and review of antibiotic stewardship program policy, the facility failed ensure unnecessary antibiotic was reviewed and discontinued as required. This affected one (#30) of five residents reviewed for unnecessary medication use. The facility census was 77. Residents Affected - Few Findings include: Review of medical record for Resident #30 revealed an admission date of 05/29/18 with diagnosis including dementia with behavioral disturbances, hypertension, major depression, overactive bladder, polyarthritis, altered mental status, constipation, insomnia, weakness and anxiety disorder. Review of Hospital record dated 07/01/18 documented was admitted to the hospital on [DATE]. Resident #30 was found to have a urinary tract infection (UTI) and the culture and sensitivity resulted in an extended spectrum beta-lactamase (ESBL) which is a multi-drug resistant organism (MDRO). She was then started on Augmentin 875/125 milligrams twice a day by mouth for 10 days. Further review of culture an sensitivity report documented Ciprofloxacin was resistance to the UTI organism ESBL. Review of physicians order dated 07/04/18 documented Resident #30 was ordered Augmentin 875/125 milligrams twice a day by mouth for a remainder of eight days for a UTI which was documented as sensitive to the organism growth of ESBL. Review of nursing note dated 07/06/18 documented the resident was readmitted to the facility on [DATE] with orders to continue antibiotic Augmentin 875/125 milligrams twice a day by mouth for a remainder of eight days for a UTI. Review of monthly medication administration record (MAR) sheet dated documented Resident #30 received 6 days Augmentin 875/125 milligrams twice a day by mouth starting on 07/04/18 through 07/09/18. Review of nursing notes dated 07/10/18 documented the physician was in to see Resident #30 due to allergic reaction to the current use of an antibiotic Augmentin. At this time he order a new antibiotic ciprofloxacin 500 milligrams twice a day to be given by mouth for seven days for an UTI which was resistant to the organism growth of ESBL. Review of physician order dated 07/10/18 documented an order for ciprofloxacin 500 milligrams to be given twice a day by mouth for seven days. Review of MAR documented Resident #30 received seven days of ciprofloxacin 500 milligrams twice a day from 07/10/18 through 07/16/18. Review of antibiotic stewardship tracking log was started on Augmentin for UTI which was appropriate. Further review documented on the same line the change to Ciprofloxacin on 07/10/18 for seven days. Interview on 10/16/18 at 12:39 P.M., with Infection Control Nurse/Licensed Practical Nurse #400 verified she must have missed the part of being ciprofloxacin resistant to the organism as part of her antibiotic stewardship program review. She further verified it should have been discontinued when the physician ordered it because it wasn't necessary antibiotic/medication use since the organism was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 8 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0757 resistance to the ciprofloxacin ordered. Level of Harm - Minimal harm or potential for actual harm Review of policy titled Antibiotic Stewardship dated 10/17/18, documented the facility staff including work in collaboration to prevent the unnecessary use of antibiotics. Further review documented care community will review antibiotics appropriateness and suggest alternatives in consideration with the physician and the pharmacist. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 9 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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, family and staff interviews, the facility failed to obtain from an outside source, routine dental services to meet the dental needs of a resident. This affected one (#61) of two residents reviewed for dental needs. The total resident census was 77. Residents Affected - Few Findings include: Medical record review for Resident #61 found an admission date of 02/28/14, with diagnoses: vascular dementia with behavioral disturbances, borderline personality disorder, hemiplegia affecting left non-dominant side, allergic rhinitis, restlessness and agitation, dry eye syndrome, anemia, dementia with behavioral disturbance, schizoaffective disorder, major depressive disorder recurrent severe with psychotic symptoms, anxiety disorder, mental disorder not otherwise specified, cortical age related cataract, blindness both eyes, hypertension, heart failure, tachycardia, dysphagia, and cerebrovascular disease. Review of the an annual minimum data set assessment dated [DATE], identified Resident #61 with broken natural teeth. The care area assessment reflected that Dental was triggered with a decision to care plan. The care plan was reviewed and covered broken, missing teeth with the necessity for staff to do all oral care for him. Interview on 10/15/18 at 10:52 A.M., with a family member of Resident #61, found the resident to have 7-9 bad, broken teeth. The family member stated the resident saw a dentist earlier in the year, but the teeth need to be pulled and that dentist could not do it. The family member stated he needed to have the teeth pulled by an oral surgeon that would accept Medicaid payment and the facility had not source to do this. Medical record review found documentation that indicated the resident was seen by a general dentist on 04/19/18 who made a referral to the Ohio State college of dentistry for oral surgery. Review of a progress note by Resident Services Coordinator (RSC) #317, dated 04/19/18, reflected the resident returned from office visit at local dentist at 4:10 P.M., with no signs or symptoms of distress noted. Resident received referral for oral surgeon at Ohio State college of dentistry for removal of broken teeth, several broken teeth are causing pain. Resident's mother updated on visit and referral. Information passed to case manager to set up appointment and transportation. No further action was taken at that time. Review of the resident services coordinator progress notes dated 06/04/18 stated the staff member followed up with the local dental center regarding referral to oral surgeon at Ohio State college of dentistry. Staff member stated that referral was made to Ohio State college of dentistry because of the amount of broken teeth and pain resident has, the dentist felt that Ohio State college of dentistry has best equipment and expertise to assist resident. RSC #317 left message with Ohio State college of dentistry oral surgery department checking on the status of referral. On 06/08/18, the Ohio State college of dentistry oral surgery department stated they denied the referral for the resident due to not taking any new patients at this time. RSC #317 contacted the local Dental Center to request a new referral for a different oral surgeon. Interview on 10/16/18 at 11:52 A.M., with RSC #317, stated she called the local dental office and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 10 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 they still have not found an oral surgeon to refer resident to. She verified the facility has not attempted to find an oral surgeon for resident. The facility had no policy to address referrals for dental care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 11 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, review of facility Legionella risk assessment, review of facility's policies, review of form A 0010 and staff interviews, the facility failed to provide appropriate monitoring to reduce the risk of Legionella exposure as required for long term health care facility's. In addition the facility failed to follow appropriate infection control policy and procedure related to handling residents who are on contact isolation for communicable diseases. This had the potential to effect all 77 of 77 residents residing in the facility. Residents Affected - Many Findings include 1.) Review of the facility risk assessment dated [DATE], documented the facility should have a water management program for the hot and cold water distribution to reduce the risk of Legionella growth and spread. Review of Form A-0010 documented on 05/15/18 and 08/04/18, all areas assessed as a risk were not being monitored as required per the facility's Appendix B Legionella management plan for control and prevention. There were some temperatures completed these months but without weekly documentation as described in the facilities policy. There was also quarterly chlorine testing but it was only documented for the hot and cold water heaters. Interview on 10/17/18 at 9:35 A.M., with Environmental Service Supervisor #510 verified he was not doing the monitoring as it was required per the facilities risk assessment and policy. He verified he was only monitoring the entry point to the building and at the end point in the building. He stated this is what it said at the bottom of his monitoring sheet. he also revealed quarterly chlorine testing was completed but only at the cold and hot water heaters. He further verified he was not aware he should have been conducting monitoring at all the point on Appendix B as required per the facility assessment and policy but will be starting to monitor them from now on. Review of the facility policy titled Legionella policy-environmental date 02/17/16, documented the facility will implement control measure to reduce the potential growth and spreading of Legionella. Further review documented Appendix B Legionella management plan for control and prevention will identify the control measures that included quarterly testing for chlorine levels at the cold distribution for central shower/circulation tub and the hot distribution chlorine levels kitchen of the kitchen appliances and central shower/circulation tub. Further review also indication weekly water temperatures will be completed for water heaters, mixing valves, sinks and showers in residents rooms, central shower/circulation tub and kitchen appliances. All the other areas will be visually monitored for evidence of debris and or biofilm which cause contamination. The policy identifies to document this on form A-0010. 2) Observation on 10/16/18 at 11:40 A.M., of meal trays being delivered to resident rooms revealed State Tested Nurse Assistant (STNA) #315 was to deliver a meal tray to Resident #77. STNA #315 obtained the lunch tray from the B hall kitchenette and walked to the residents room. The STNA knocked on the resident's door, walked in the room, and place the meal tray on the bedside table of Resident #77. With ungloved hands, STNA #315 moved the bedside table, leaned towards the resident, and touched Resident #77 on the shoulder several times in attempt to wake the resident. Continued observation revealed Resident #77 requested to eat the meal at a later time. STNA #315 picked up the meal tray and exited the residents room without washing hands or placing the meal tray in a bag. The STNA then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 12 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many carried the meal tray through B hall dining room to the kitchenette and handed the tray to the dietary manager, with the meal tray passing over the food serving area which contained the food being used for resident afternoon meals. Review of the medical record for Resident #77 revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic kidney disease, dependence on renal dialysis, type two diabetes mellitus, protein calorie malnutrition, atrial fibrillation, hypertension, visual loss, and peripheral vascular disease. Review of a laboratory result dated 09/30/18 revealed Resident #77 had positive test results for clostridium difficile. Review of the physician orders revealed the resident was being treated for the clostridium difficile with the glycopeptides medication vancomycin. Interview on 10/16/18 at 11:45 A.M., with STNA #315 revealed the STNA was aware staff were to utilize contact precautions when providing care for Resident #77. STNA #315 verified he/she did not don gloves or any other personal protective equipment prior to making contact with Resident #77. The STNA further verified he/she did not bag the meal tray or wash hands prior to leaving the residents room. STNA #315 revealed he/she did not know the proper procedure for handling a meal tray that was removed from an isolation room. Review of a policy titled, Transmission Based Precautions General Principles undated, revealed trays to residents on transmission based precautions are delivered last. Nursing personnel will wear appropriate protective apparel when taking tray service in to the room. The meal tray is to be bagged prior to leaving the residents room. Bagged trays are to return to the kitchen and washed last. The policy further revealed employees should wear gloves when handling dirty dishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 13 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0881 Implement a program that monitors antibiotic use. 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 staff interview and review of antibiotic stewardship program policy, the facility failed ensure an antibiotic was assessed and reviewed as required through the facility antibiotic stewardship program to ensure unnecessary use of antibiotic. This affected one (#30) of four residents reviewed for antibiotic use. The facility census was 77. Residents Affected - Few Findings Include: Review of medical record for Resident #30 revealed an admission date of 05/29/18 with diagnosis including dementia with behavioral disturbances, hypertension, major depression, overactive bladder, polyarthritis, altered mental status, constipation, insomnia, weakness and anxiety disorder. Review of Hospital record dated 07/01/18 documented was admitted to the hospital on [DATE]. Resident #30 was found to have a urinary tract infection (UTI) and the culture and sensitivity resulted in an extended spectrum beta-lactamase (ESBL)which is a multi-drug resistant organism (MDRO). She was then started on Augmentin 875/125 milligrams twice a day by mouth for 10 days. Further review of culture an sensitivity report documented Ciprofloxacin was resistance to the UTI organism ESBL. Review of physicians order dated 07/04/18 documented Resident #30 was ordered Augmentin 875/125 milligrams twice a day by mouth for a remainder of eight days for a UTI which was documented as sensitive to the organism growth of ESBL. Review of nursing note dated 07/06/18 documented the resident was readmitted to the facility on [DATE] with orders to continue antibiotic Augmentin 875/125 milligrams twice a day by mouth for a remainder of eight days for a UTI. Review of monthly medication administration record (MAR) sheet dated documented Resident #30 received 6 days Augmentin 875/125 milligrams twice a day by mouth starting on 07/04/18 through 07/09/18. Review of nursing notes dated 07/10/18 documented the physician was in to see Resident #30 due to allergic reaction to the current use of an antibiotic Augmentin. At this time he order a new antibiotic ciprofloxacin 500 milligrams twice a day to be given by mouth for seven days for an UTI which was resistant to the organism growth of ESBL. Review of physician order dated 07/10/18 documented an order for ciprofloxacin 500 milligrams to be given twice a day by mouth for seven days. Review of MAR documented Resident #30 received seven days of ciprofloxacin 500 milligrams twice a day from 07/10/18 through 07/16/18. Review of antibiotic stewardship tracking log was started on Augmentin for UTI which was appropriate. Further review documented on the same line the change to Ciprofloxacin on 07/10/18 for seven days. Interview on 10/16/18 at 12:39 P.M., with Infection Control Nurse/Licensed Practical Nurse #400, verified she must have missed the part of being ciprofloxacin resistant to the organism as part of her antibiotic stewardship program review. She further verified it should have been discontinued when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 If continuation sheet Page 14 of 15 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/18/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celina Manor 1001 Myers Road Celina, OH 45822 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the physician ordered it because it wasn't necessary antibiotic/medication use since the organism was resistance to the ciprofloxacin ordered. Review of policy titled Antibiotic Stewardship dated 10/17/18 documented the facility staff including work in collaboration to prevent the unnecessary use of antibiotics. Further review documented care community will review antibiotics appropriateness and suggest alternatives in consideration with the physician and the pharmacist. Event ID: Facility ID: 365377 If continuation sheet Page 15 of 15