Health inspection·December 19, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on closed medical record review, staff interview and facility policy review the facility failed to ensure residents received discharge notices timely. This affected one (Resident #84) of one reviewed for hospitalization. The facility census was 85. Findings include: Review of the closed medical record of Resident #84 revealed an admission date of 09/24/19. Diagnosis included malignant neoplasm of bladder unspecified. Review of the progress notes dated 10/17/19 revealed Resident #84 went to a scheduled doctors appointment with his daughter. He was sent to the emergency department and was admitted to the hospital related to multiple blood clots in both legs. The medical record was silent for any discharge notice being sent to the resident and/or family. Interview on 12/19/19 at 4:05 P.M. with the Director of Nursing verified no transfer notice had been sent to Resident #84 or his family. Review of the facility policy titled Admission, Transfer and Discharge Rights dated 02/2018 revealed a notice of transfer or discharge will be given to the resident and sent certified mail to the resident's sponsor, family or guardian, if known. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 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 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on closed record review, staff interview and facility policy review the facility failed to provide one resident, #84, with a bed hold notice upon discharge to the hospital. The facility census was 85. Residents Affected - Few Findings include: Review of the closed medical record of Resident #84 revealed an admission date of 09/24/19. Diagnosis included malignant neoplasm of bladder unspecified. Review of the progress notes dated 10/17/19 revealed Resident #84 went to a scheduled doctors appointment with his daughter. He was sent to the emergency department and was admitted to the hospital related to multiple blood clots in both legs. The record was silent for any bed hold notice having been sent to the resident and/or family. Interview on 12/19/19 at 4:05 P.M. with Office Manager #700 provided verified no transfer notice was sent to Resident #84 or his family. Review of the facility document titled Bed Holds and Leave of Absence dated 03/2017 revealed the Medicaid program will pay for the costs of holding your bed at the facility. so long as the number of bed hold days has not been exceeded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, review of pharmacy recommendations and review of facility policy, the facility failed to ensure respiratory medications were available from the pharmacy. This affected one (Resident #36) of one resident reviewed. The facility identified four residents who received rescue respiratory medications. The census was 85. Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/12/18 with a re-entry dated of 06/13/18. Diagnoses included acute and chronic respiratory failure with hypoxia, mild intermittent asthma, chronic obstructive pulmonary disease (COPD), acute bronchitis and emphysema. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively intact with the need for oxygen. Review of the plan of care dated 12/20/18 revealed the resident had Asthma and COPD and could become short of breath if laying flat. Intervention included to give aerosol or bronchodilators as ordered. Monitor and document any side effects and effectiveness Review of the physician's order dated 07/05/19 revealed Ventolin (bronchodiliator) 200 microgram (mcg) to give one inhalation every four hours as needed (PRN) and resident may keep at bedside. An order for Budesonide Formoterol Fumarate aerosol 160 mcg- 4.5 mcg to give two puff via inhalation orally twice a day (BID) related to COPD. Review of the Medication Administration Record (MAR) for 12/2019 revealed Budesonide Formoterol Fumarate aerosol 160 mcg- 4.5 mcg was not given on 12/13/19 at bed time (HS), 12/16/19 and 12/17/19 upon rising. Review of the pharmacy delivery route packing slip dated 12/17/19 at 12:06 P.M. revealed the facility received Resident #36's Budesonide Formoterol Fumarate Aerosol 160 mcg- 4.5 mcg. Interview with Resident #36 on 12/18/19 at 9:27 A.M. revealed he had issue about not being allowed to keep his rescue inhaler in his room. He stated he preferred to keep his rescue inhaler in the room due to he didn't want to have to wait for the nurse to get if for him. Follow up interview with Resident #36 on 12/19/19 at 10:25 A.M. revealed he still did not have his rescue inhaler at his bedside. He stated he had asked staff to keep it and they told him he was not allowed. Observation on 12/19/19 at 10:30 A.M. of the medication cart for C-Hall with Licensed Practical Nurse (LPN) #208 revealed Resident #36 did not have Ventolin 200 mcg inhaler in the cart Interview during the observation with LPN #208 revealed she looked at the order for Ventolin 200 mcg which indicated may be kept at bedside, but it was documented as other. She explained this medication probably was never received by the pharmacy due to the order was put in wrong. LPN #208 revealed it should have indicated pharmacy in this area (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 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 0755 Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 12/19/19 at 10:45 A.M. revealed pharmacy had not sent Resident #36's Ventolin rescue inhaler due to it did not indicate pharmacy on the order in point click care. Interview with Registered Nurse (RN) #307 on 12/19/19 at 2:00 P.M. verified she did not know why the Budesonide Formoterol Fumarate was not given on 12/13/19 at HS and 12/16/17 and 12/17/19 at rising. Residents Affected - Few Review of the facility policy Pharmaceutical Service dated 1020/03 revealed the manor must provide routine and emergency drugs and biologicals to it's residents by providing pharmaceutical services including procedure that assure the accurate acquiring, receiving and dispensing of all drugs to meet the needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy review the facility failed to ensure staff witnessed residents take their medications. This affected one (Resident #58) of one resident observed during a random observation. The facility identified 17 Residents (#5, #10, #19, #20, #32, #33, #56, #57, #58, #60, #62, #69, #73, #75, #78, #80, and #81 who resided on the B Hall. The facility further failed to ensure the glucose control solution was dated once opened to ensure potency and accuracy. This had the potential to affect three Residents (#2, #4 and #44) residing in the E hall who had blood glucose monitoring. The facility census was 85. Findings include: 1. Review of the medical record of Resident #58 revealed an admission date of 02/14/18. Diagnoses included end stage renal disease chronic kidney disease stage five, abnormalities of breathing, gastro-esophageal reflux disease and essential hypertension. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #58 was cognitively intact. Observation on 12/19/19 at 10:15 A.M. revealed Resident #58 seated in a wheelchair at a table in the dining room of B hall. Nine various medication tablets were lying on the table in a small pile. Resident #58 was holding a four-ounce plastic cup that contained a clear liquid. Resident #58 took two large tablets and this surveyor asked him to stop until a staff member was present. The surveyor asked an unidentified State Tested Nursing Assistant (STNA) to enter a nearby room and ask Corporate Registered Nurse (CRN) #900 to come and assist. CRN #900 arrived at the table and verified the remaining seven medications and observed Resident #58 ingest the remaining seven tablets. CRN #900 encouraged him to drink all of the water. Review of the medication administration record for 12/19/19 revealed Registered Nurse (RN) #302 documented she had administered the resident the following medications: azathioprine (an immunosuppressant) 50 milligrams (mg) two tablets; B complex C with folic acid (vitamin supplement) one mg; cholecalciferol (a vitamin supplement) 2000 units; Fibercon (a laxative) 625 mg; Miralax (a laxative) 17 grams; Montelukast sodium (for abnormal breathing) 10 mg; Protonix (for reflux), 40 mg; Coreg (for hypertension) 12.5 mg; and Sevelamer carbonate (for elevated phosphorous level) 800 mg. Interview on 12/19/19 at 10:20 A.M. with RN #302 revealed she had thought it was acceptable to allow Resident #58 to ingest his medications unsupervised as he was alert and oriented. She further identified the liquid in the four-ounce plastic cup to contain Miralax. Review of the facility policy titled Medication Storage in the Facility dated 09/2017 revealed medications are stored safely and securely and accessible only to licensed nursing personnel authorized to administer medications. 2. Observation on 12/19/19 at 9:30 A.M. with Licensed Piratical Nurse (LPN) #202 revealed an opened and undated box containing two vials of glucose control solution. Each of the vials had the words discard three months after opening on them. Interview at the time of the observation with LPN #202 verified the vials of glucose control (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365377 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 365377 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2019 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 0761 solution was opened and undated. 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: 365377 If continuation sheet Page 7 of 7