Inspection·September 26, 2019

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, staff interview, and policy review, the facility failed to monitor a resident's dialysis access per facility policy. This affected one (#17) of one resident reviewed for dialysis. The facility census was 55. Residents Affected - Few Findings include: Review Resident #17's medical record revealed an admission date of 02/19/18. Diagnoses included: end stage renal disease, essential hypertension, heart failure, muscle weakness, gastro-esophageal reflux disease without esophagitis, anemia, acute myocardial infarction, overactive bladder, constipation, gout, acute embolism and thrombosis of deep veins of right upper extremity. Interview on 09/26/19 at 7:11 A.M. with Resident #17 revealed Resident #17 stated the staff don't check her arm very often here, but they do at dialysis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #17 was cognitively intact with a Brief Interview Mental Status (BIMS) of 15. Resident #17 had no rejection of care during the assessment period. Resident #17 received dialysis services. Review of the care plan dated 06/25/19 revealed Resident #17 had renal failure resulting in the need for dialysis. Resident will be free from complications associated with dialysis. Appropriate goal and interventions were included in the care plan specifically, monitor dialysis access as ordered. Review of the current physician orders revealed there was no order for monitoring the dialysis access. Review of the Treatment Administration Record for 08/2019 and 09/2019 revealed there was documentation of monitoring the dialysis access. Interview on 09/26/19 at 9:55 A.M. with the Director of Nursing revealed there was no order to monitor the dialysis access and there was no documentation of monitoring the dialysis access. Review of the policy titled Guidelines for Monitoring Shunt: Hemodialysis Arteriovenous Access, dated 05/22/18, revealed to monitor the Arteriovenous shunt daily for redness, swelling, signs and symptoms of infections, complaints of pain, local warmth, exudates, tenderness, numbness, tingling, and extremity swelling distal to access. Monitor the Arteriovenous shunt daily for thrill and bruit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 2 of 6 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, staff interview, and review of food menus and spreadsheets, the facility failed to serve appropriate food servings to residents with a pureed diet. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Findings include: Observation on 09/25/19 at 12:08 P.M., revealed [NAME] #560 serving residents meals from the steam table in the main dining room. [NAME] #560 served all meals to residents in the main dining room and restorative and was asked what scoop sizes were used while serving food items. Interview on 09/25/19 at 12:14 P.M., with [NAME] #560 stated the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach were served using a #10 (3/8 cup) scoop. Review of menu for the spring and summer Midwest 2019 week 2 revealed the lunch meal was cornflake chicken breast, scalloped potatoes, sauteed cabbage and spinach, a Southern biscuit, cherry cobbler, butter cup, coffee and tea, and garnish. Review of a spreadsheet for the spring and summer Midwest 2019 diet revealed purred cornflake chicken breast was to be served with a #6 (5/8 cup), pureed scalloped potatoes with a #8 (1/2 cup), and pureed sautéed cabbage and spinach with a #12 (1/3 cup) scoop. Interview on 09/25/19 at 12:30 P.M., with [NAME] #560 and Dietary Manager #290 verified the incorrect scoop sizes were used when serving the pureed cornflake chicken breast, scalloped potatoes, and sautéed cabbage and spinach in the main and restorative dining rooms on 09/25/19. Interview on 09/26/19 at approximately 10:30 A.M., with Director of Health Services #101 verified none of the 11 (#8, #16, #21, #22, #23, #27, #29, #31, #34, #38, and #44) residents with orders for pureed diets had any significant weight loss in the last 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 3 of 6 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of food recipes, and review of a facility policy, the facility failed to provide nutritional and appetizing bread for a pureed meal. This affected nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms. The facility identified two (#27 and #31) additional residents with orders for pureed diets who received their meals in their rooms. The census was 55. Residents Affected - Some Findings include: Observation on 09/25/19 at 11:25 A.M., revealed [NAME] #400 preparing pureed textured foods in the facility kitchen. [NAME] #400 explained the recipe for pureed textured foods had a minimal serving size of 25 servings, and since the facility had less than 25 residents on pureed diets they would recalculate the recipe to make it for 15 servings. [NAME] #400 asked Dietary Manager #290 to recalculate a recipe for pureed bread to make 15 servings instead of 25. Dietary Manager #290 presented [NAME] #400 with a revised recipe to aide in making pureed bread for the lunch meal. Review of an undated pureed bread recipe number 157 revealed the recipe was set up for serving sizes of 25, 50, 75, 100, and 150 and ingredients including pureed bread mix, hot water, and low-sodium chicken base. Review of the undated, unnamed and revised recipe given to [NAME] #400 revealed an example for ingredients in black and white cookies for eight, sixteen, forty, eighty, and 120 servings with ingredients of flour, baking powder, salt, and milk. The recipe did not address ingredients for pureed bread or the quantity of the ingredients needed. Further observation on 09/25/19 at 11:30 A.M., revealed [NAME] #400 removed slices of bread from the steamer and placed them in the food processor mixing it with an undetermined amount of hot water, melted butter, and chicken broth. After all food items were blended together, [NAME] #400 used a spatula to scrap the pureed bread from the food processor into a metal holding pan at which time the consistency of the pureed bread was very thin in an almost liquid form. Interview 09/25/19 at 11:40 A.M., with [NAME] #400 stated she would place the pureed bread back in the steamer and it would thicken up. Observation on 09/25/19 at 12:08 P.M., revealed [NAME] #560 serving residents meals from the steam table in the main dining room. Further observation revealed [NAME] #560 scoop pureed bread from the steam table and place it on plates. The consistency of the pureed bread was very runny and did not require [NAME] #560 to use the clicker on the side of the scoop. When [NAME] #560 placed the scoop into the pureed bread and lifted the scoop, pureed bread mixture was dripping off the scoop, and when the pureed bread was plated it did not hold a form and ran on the plate into other food items. Interview on 09/25/19 at 12:30 P.M., with [NAME] #560 and Dietary Manager #290 stated the pureed bread was too runny and should have been more formed. Dietary Manager #290 stated he did not observe the pureed bread after [NAME] #400 prepared it. The facility identified nine (#8, #16, #21, #22, #23, #29, #34, #38, and #44) residents with orders for pureed diets who were served food in the main and restorative dining rooms on 09/25/19 between (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 4 of 6 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0804 12:00 P.M. and 12:30 P.M. Level of Harm - Minimal harm or potential for actual harm Review of a facility policy titled, Standardized Recipes, dated 05/31/16, revealed any recipe changes made by the Director of Food Services should be reviewed and approved by the Registered Dietitian. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 5 of 6 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 365407 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadows of Kalida 755 Ottawa Street Kalida, OH 45853 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to properly maintain the flooring in a resident's room. This affected one of 46 resident rooms observed. The facility census was 55. Findings include: Observation on 09/23/19 at 11:16 A.M., revealed three large holes in the tile flooring in resident room [ROOM NUMBER]. The three holes are approximately two inches by four inches, four inches by six inches, and six inches by nine inches. The holes are near a resident's recliner. Interview on 09/25/19 at 11:38 A.M., with the Director of Plant Operations #102 verified there are holes in the tiling flooring of resident room [ROOM NUMBER]. Director of Director of Plant Operations #102 verified a work order had not been received and the flooring definitely should have been fixed. Further interview at 12:04 P.M., verified the tile had completely ripped through to the under layment flooring. Interview on 09/26/19 at approximately 7:30 A.M., with Administrator #100 verified the flooring should have been replaced. Review of facility policy titled,Flooring Preventative Maintenance, dated 02/06/18, verified vinyl tile is inspected for chipping and cracking quarterly and replaced as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365407 If continuation sheet Page 6 of 6