Health inspection·August 25, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Review of Resident #103's care plan, last updated 07/27/22, revealed there were no interventions for unspecified heart failure or seizures in the care plan. Interview on 08/24/22 at 1:18 P.M. with Registered Nurse (RN) #139 and RN MDS Support #185 verified Resident #103's diagnoses of unspecified heart failure and seizures were not addressed in the care plan. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 2 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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, resident interview, and staff interview, the facility failed to ensure staff trimmed the fingernails of residents who were unable to carry out activities of daily living. This affected one (Resident #22) out of 47 residents reviewed for personal hygiene. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/08/22. Diagnoses included left femur fracture, paranoid schizophrenia, unspecified psychosis, and anxiety. Review of the admission Minimum Data Set assessment, dated 06/13/22, revealed Resident #22 was cognitively intact and required extensive assistance of two staff for personal hygiene. Observations on 08/22/22, 08/23/22, and 08/24/22 revealed Resident #22's fingernails were past the fingertips. Resident #22's nails were clean. Interview on 08/23/22 at 11:00 A.M. with Resident #22 revealed he preferred his nails to be shorter and no one had trimmed them for quite a while. Interview on 08/24/22 at 11:00 A.M. with Director of Health Services and Registered Nurse Clinical Campus Support #184 revealed they were aware Resident #22 stated his fingernails were longer than he preferred. Observation on 08/25/22 at 8:00 A.M. revealed Resident #22's fingernails remained the same length. Interview with Resident #22 at the time of the observation revealed he preferred his nails were cut shorter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 3 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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 and staff interview, and facility policy review, the facility failed to ensure residents blood sugar levels were checked as ordered. This affected two (Resident #7 and #29) out of five residents reviewed for unnecessary medications. The facility census was 47. Residents Affected - Few Findings include: 1. Review of Resident #29's medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included but were not limited to type two diabetes mellitus without complications, acute respiratory failure with hypoxia, and chronic combined systemic and diastolic heart failure. Review of Resident #29's Minimum Data Set (MDS) assessment, dated 07/01/22, revealed the resident was cognitively intact and received insulin. Review of Resident #29's physician order, dated 08/10/22, revealed an order for Novolog (insulin) three milliliter (ML) 100 units/ML per sliding scale based on blood sugar results four times a day. Review of Resident #29's Medication Administration Record (MAR), dated August 2022, revealed on 08/23/22 from 4:00 P.M. to 5:00 P.M., Resident #29 did not have his blood sugar level checked. Review of a note entered on 08/23/22 at 10:17 P.M., revealed Resident #29's blood sugar check was not completed by the previous nurse. Interview on 08/24/22 at 9:29 A.M. with Resident #29 revealed his blood sugar was not checked yesterday (08/23/22) prior to dinner. Interview on 08/24/22 at 10:35 A.M. with Registered Nurse (RN) #131, verified Resident #29's blood sugar was not checked on 08/23/22 prior to the evening meal. RN #131 stated there were two new admissions and she did not have time. 2. Review of Resident #7's medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included but were not limited to type two diabetes mellitus with diabetic chronic kidney disease, end stage renal disease, and heart failure. Review of Resident #7's MDS assessment, dated 08/09/22, revealed Resident #7 was cognitively intact and received insulin. Review of Resident #7's physician order, dated 07/09/22, revealed an order for Novolog Flexpen U-100 Insulin administered per sliding scale based on blood sugar results. Review of Resident #7's MAR, dated August 2022, revealed on 08/23/22 from 4:00 P.M. to 5:00 P.M., Resident #7 did not have his blood sugar level checked. Review of a note entered on 08/23/22 at 10:16 P.M., revealed Resident #7's blood sugar check was not completed by the previous nurse. Interview on 08/24/22 at approximately 4:15 P.M. with Registered Nurse MDS Support #185 verified on 08/23/22, prior to dinner, Resident #7 did not have his blood sugar checked as ordered. Review of the policy titled Glucometer Standard Operating Procedure, reviewed 03/17/22, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 4 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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 blood glucose monitoring shall be completed for the resident per the physician order. 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: 365405 If continuation sheet Page 5 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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, observation, resident and staff interview, and review of facility policy, the facility failed to ensure resident smoking supplies were stored in a locked area. This affected one (Resident #7) out of one resident reviewed for smoking and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included but were not limited to hypertensive heart disease with heart failure, acute respiratory failure with hypoxia, and type two diabetes mellitus without complications. Review of Resident #29's Minimum Data Set assessment, dated 07/01/22, revealed Resident #29 was cognitively intact. Interview on 08/22/22 at 2:07 P.M. with Resident #29 revealed Resident #29 stored cigarettes and a lighter in his dresser drawer. Observation on 08/24/22 at 8:35 A.M. revealed Resident #29's resident room door was open and State Tested Nursing Assistant (STNA) #182 was observed to open Resident #29's unlocked dresser drawer and hand Resident #29 his cigarettes and lighter. Interview on 08/24/22 at 8:40 A.M. with STNA #182 verified Resident #29's cigarettes and lighter were stored unlocked in the resident's room. Review of the facility policy titled Smoke Free Environment, last reviewed 12/01/21, revealed it is the policy of the facility to provide a Smoke Free Environment for employees, residents, and visitors. The facility and grounds have been designated tobacco free. Smoking and the use of tobacco products is prohibited anywhere on the facility property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 6 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and staff interview, the facility failed to maintain and store a rigid suction catheter in clean and sanitary manner. This affected one (Resident #20) out of one resident reviewed for respiratory suctioning. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission date of 03/29/22. Diagnoses included sepsis due to methicillin resistant staphylococcus aureus and pseudomonas, acute respiratory failure, and acquired absence of larynx. Review of the admission Minimum Data Set assessment, dated 06/10/22, revealed Resident #20 was cognitively intact and required extensive assistance of one staff for personal hygiene. The assessment further indicated respiratory suctioning was performed. Observation on 08/22/22 at 10:30 A.M. revealed a rigid suction catheter, attached to a suction hose, was draped over the suction machine in Resident #20's room. The tip of the catheter was exposed to the air and was noted to be crusted with a dark brown substance. Interview with Resident #20 at the time of the observation revealed he used the suction catheter to remove secretions from his tracheostomy stoma and then draped it over the machine. Resident #20 indicated he was only able to see shadows and was unaware of the condition of the catheter. Interview on 08/22/22 at 10:45 A.M. with Registered Nurse Clinical Campus Support #184 verified the tip of Resident #20's rigid suction catheter was crusted with a dark brown substance and was exposed to air. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 7 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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 - Some 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, observation, staff interview, and review of facility policy, the facility failed to ensure medications were not left unattended at bedside. This affected one (Resident #34) out of one resident reviewed for self-administration of medication and had the potential to affect three additional residents (#4, #9, and #28) who were identified by the facility as being cognitively impaired and independently mobile. The facility census was 47. Findings include: Review of the medical record revealed Resident #34 was admitted on [DATE]. Diagnoses included polyneuropathy, unspecified protein-calorie malnutrition, hypocalcemia, hypertensive heart disease with heart failure, acute on chronic systolic (congestive) heart failure, hypothyroidism, hyperlipidemia, and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed Resident #34 was cognitively intact. Review of Resident #34's physician order, dated 07/28/22, revealed an order for sucralfate one gram four times a day. Additional review of Resident #34's medical record revealed the Resident #34's medical record was silent for a self-medication assessment, physician order for self-administration of medication, and plan of care interventions for self-administration of medication. Observation on 08/22/22 at 1:30 P.M. of Resident #34's room revealed a medication cup on Resident #34's tray table with a single large white pill in the cup. Resident #34 was in bed with bedding over his face and body, and Resident #34 was not responding to questions. Interview on 08/22/22 at 1:37 P.M. with Licensed Practical Nurse (LPN) #103 verified he/she left a sucralfate (antacid medication) pill on Resident #34's bedside table. LPN #103 stated Resident #34 instructed her to leave it and that he would take it later. Review of the policy titled Medication Administration, revised November 2018, revealed residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. In addition, the resident is always observed after administration to ensure that the dose was completely ingested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 8 of 9 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 365405 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Delphos The 800 Ambose Drive Delphos, OH 45833 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, observation, and staff interview, the facility failed to ensure wound measurements were accurately documented on a wound assessment. This affected one (Resident #22) out of two residents reviewed for pressure ulcers. The facility census was 47. Findings include: Review of the medical record for Resident #22 revealed an admission date of 06/08/22. Diagnoses included left femur fracture, unspecified psychosis, paranoid schizophrenia, and anxiety. Review of the Wound Management Detail Report, dated 08/24/22, by Director of Health Services (DHS), revealed Resident #22's wound measured five cm in length, 3.2 cm in width, and 0.2 cm in depth. The wound was documented as unstageable with slough and/or eschar. The tissue type was slough with 25% of wound covered with granulation tissue and 75% of the wound covered with slough tissue. Observation on 08/24/22 at 2:00 P.M. of Resident #22's wound dressing change, performed by DHS, revealed the wound had 75% slough in the wound bed. DHS measured the wound and stated it was five cm in length and 3.2 cm in width. She did not indicate, nor was it observed, a depth measurement. Interview on 08/25/22 at 1:30 P.M. with DHS and Registered Nurse Clinical Campus Support #184 verified Resident #22's wound documentation on 08/24/22 was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365405 If continuation sheet Page 9 of 9