Health inspection·September 27, 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 record review, resident interview, and staff interview the facility failed to ensure residents were informed of medication changes. This affected one (#49) of one resident reviewed for care planning. The facility census was 66. Findings include: Review of Resident #49's medical record revealed an admission date of 06/04/18 with diagnoses of vascular dementia without behavioral disturbances, anxiety disorder, major depressive disorder, heart failure, chronic kidney disease, and hypertension (high blood pressure). Review of the modification of the quarterly minimum data set 3.0 assessment dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. Review of Resident #49's progress notes from 08/18/18-09/26/18 revealed a progress notes on 08/21/18 at 2:47 A.M. to discontinue Lasix (diuretic), and change to Bumex (diuretic) 1 milligram (mg) two times a day, Aldactone (diuretic) 25 mg daily, start bacid (probiotic) one tablet by mouth two times a day for 20 days and to check the basic metabolic panel (BMP) on 08/27/18, the daughter was notified. On 08/21/18 at 6:47 P.M., the residents' daughter was updated on new orders for Colace (stool softener) to 100 mg daily as needed, add Metamucil one scoop daily for five days, and Imodium one capsule four times a day as needed for ten days and to discontinue Colace 100 mg two time a day. On 09/01/18 at 12:02 A.M. the residents daughter was notified of new order for Zaroxolyn (diuretic). A progress note on 09/14/18 at 2:48 P.M. revealed there was a new order received for Tylenol extra strength one tablet at bedtime, and the daughter was notified. Further review of Resident #49's medical record failed to identify Resident #49 was ever informed of these medication changes. Interview with Resident #49 on 09/24/18 at 10:39 A.M. voiced he was only informed of his medication changes if he asked. Additional interview with Resident #49 on 09/26/18 at 5:03 P.M. revealed when his medications were changed, he was not informed. Resident #49 voiced the staff told his daughter, however, he would like to be informed as well, so he would know what medications he was taking. Interview with Registered Nurse (RN) #92 on 09/26/18 at 5:32 P.M. voiced if Resident #49 medications were changed staff would notify both him and his family. She voiced it would be documented in the progress notes that notification was made. Interview with Licensed Practical Nurse (LPN) #94 voiced if Resident #49's medications were changed staff would notify both the resident and his daughter. She voiced it would be documented in the progress notes that notification was made. Additional interview with LPN #94 on 09/26/18 at 6:14 P.M. confirmed there was no evidence Resident #49 was notified when his medications were changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 2 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview and policy review, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative and to the long-term care ombudsman. This affected one (#65) of one resident reviewed for hospitalizations. The facility census was 66. Findings include: Review of Resident #65's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including displaced fracture of the lateral malleolus of the right fibula, hypertension, dementia, repeated falls, history of circulatory system diseases, history of diseases of blood and blood forming organs, sprain of the deltoid ligament of the right ankle, alcohol dependence and alcohol dependence withdrawal. Review of the Minimum Data Set (MDS) assessment, dated 07/26/18 revealed Resident #65 had short-term and long-term memory problems with severely impaired cognitive skills for daily decision making. Review of the medical record for Resident #65 revealed the resident was transferred to the hospital on [DATE] at 8:47 P.M. Further review revealed no written documentation of notification of the transfer provided to the resident/representative. Additional review of the record revealed no notification to the long-term care ombudsman. During an interview with Licensed Social Worker (LSW) #106 on 09/27/18 at 11:55 A.M., it was confirmed the facility did not issue a written notice of transfer to the hospital to the resident/resident's representative concerning Resident #65's discharge to the hospital on [DATE]. LSW# 106 confirmed the long-term care ombudsman was not notified of the transfer. Review of the facility policy titled, Transfer and Discharge dated 09/26/18 revealed the facility would provide a transfer notice as soon as practicable to the resident and representative. Social services director, or designee, shall provide notice of transfer to a representative of the state long term care ombudsman via a monthly list. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 3 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interview, and policy review the facility failed to issue written notice of the bed hold policy to a resident and/or resident representative. This affected one (#65) of one resident reviewed for hospitalizations. The facility census was 66. Findings include: Review of Resident #65's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including displaced fracture of the lateral malleolus of the right fibula, hypertension, dementia, repeated falls, history of circulatory system diseases, history of diseases of blood and blood forming organs, sprain of the deltoid ligament of the right ankle, alcohol dependence and alcohol dependence withdrawal. Review of the Minimum Data Set (MDS) assessment, dated 07/26/18 revealed Resident #65 had short-term and long-term memory problems with severely impaired cognitive skills for daily decision making Further review of the medical record revealed Resident #65 was transferred to the hospital and there was no evidence the resident or representative was notified of the bed hold policy or bed hold days. During an interview with Licensed Social Worker (LSW) #106 on 09/27/18 at 11:55 A.M., it was confirmed the facility did not issue a written notice of the bed hold policy to the resident or representative related to Resident #65's discharge to the hospital on [DATE]. Review of a facility provided undated document titled, Procedure for Bed Hold Notification revealed the facility shall inform and provide in writing to the resident and/or residents representative the facility's bed hold and return to the facility policy at the time of transfer or leave of absence specifying the duration of the bed hold policy. Review of the facility policy titled, Transfer and Discharge dated 09/26/18 revealed the facility will provide a notice of the bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 4 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 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 record review, observation, and staff interview, the facility failed to implement the care plan. This affected one (Resident #28) of 20 residents reviewed during the second stage of the survey. The facility census was 66. Findings include: Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set, dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. Review of Resident #28's care plan identified the resident as being at risk for infection related to the foley catheter (a flexible tube which a clinician passes through the urethra and into the bladder to drain urine). Interventions included to keep the foley below the level of the bladder at all times. Observation of Resident #28's pressure ulcer dressing changes and foley catheter care on 09/26/18 from 8:25 A.M. until 8:55 A.M. revealed during the dressing change to Resident #28's left gluteal fold, the resident was rolled on her right side. Resident #28 was then rolled on her left side and the foley catheter bag was placed on the bed, and not kept below the level of the bladder. Interview on 09/26/18 at 9:00 A.M. with Licensed Practical Nurse (LPN) #94 confirmed the foley bag was laid on the bed and was not kept below the level of Resident #28's bladder. Additional interview with LPN #94 on 09/26/18 at 1:04 P.M. confirmed Resident #28's care plan indicated to keep the foley below the level of the bladder at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 5 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure residents received their scheduled showers. This affected one (Resident #28) of one reviewed for choices. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of hallucinations, psychotic disorder with delusions, multiple sclerosis, contracture of the left hand, type two diabetes mellitus, bipolar disorder, anxiety disorder, constipation, neurogenic bowel, and neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set, dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. The resident required total dependence of two person assist with transfers; total two person assist with dressing; total dependence two person assist with toilet use and total dependence one person assist with personal hygiene. Review of Resident #28's bathing care plan revealed to shower per facility schedule and as needed. Review of the shower schedule revealed the resident was scheduled to receive a shower on Monday, Wednesday and Friday. Review of the Activity of Daily Living task list from 08/27/18-09/25/18 revealed documentation as not applicable on five days (08/27/18, 08/31/18, 09/03/18, 09/07/18, 09/17/18), when the resident should have received a shower. Additionally, there was no evidence in Resident #28's medical record that she had received her scheduled showers. Interview with Resident #28 on 09/24/18 at 11:59 A.M. revealed she was scheduled to receive a shower on Monday, Wednesday, and Friday However, she voiced she didn't always receive them when they were scheduled. Interview with State Tested Nurse Aide (STNA) #30 and STNA #100 voiced Resident #28 was scheduled to receive a shower on day shift on Monday, Wednesday, and Friday. Interview with the Director of Nursing (DON) on 09/25/18 at 4:08 P.M. confirmed there were five days during 08/27/18-09/25/18 with no evidence Resident #28 received her showers as scheduled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 6 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 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 interview, staff interview, and policy review the facility failed to ensure the bowel regimen was initiated when a resident went without having a bowel movement for more than three days. This affected two (#11 and #28) of two residents reviewed for constipation. The facility also failed to ensure skin impairments were assessed and accurately monitored. This affected one (#61) of four residents reviewed for skin impairments. The facility census was 66. Residents Affected - Few Findings include: 1. Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of constipation and neurogenic bowel. Review of the significant change Minimum Data Set, dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. The resident required total dependence of two person assist with transfers; total two person assist with dressing; total dependence two person assist with toilet use and total dependence one person assist with personal hygiene. Review of the care plan for potential for constipation related to increased weakness and decreased mobility, initiated 07/13/17 revealed to follow the bowel management guidelines. Review of the physician orders revealed an order to initiate bowel protocol, ordered 10/13/17. There was an order for Sennosides (laxative) 8.6 milligrams (mg), one tablet by mouth every 24 hours as needed for constipation, ordered 10/15/17. There was an order for Bisacodyl suppository (laxative) 10 mg, insert one suppository rectally every 12 hours as needed for constipation ordered 10/16/17. There was an order for Miralax Powder (laxative) 17 grams by mouth every 24 hours as needed for constipation, ordered 11/03/17. There was an order for a soap suds enema every 72 hour as needed for constipation, ordered 07/24/18. Additionally, there was an order for a rectal tube for one hour every 12 hours as needed for constipation, ordered 07/23/18. Review of the bowel movement lookback report from 07/28/18-09/24/18 revealed Resident #28 went from 07/28/18-08/04/18 without having a bowel movement. She went from 08/10/18-08/15/18 without having a bowel movement. She went from 08/25/18-09/02/18 without having a bowel movement. Additionally, she went from 09/20/18-09/24/18 without having a bowel movement. Review of the 07/2018, 08/2018 and 09/2018 medication administration record (MAR) revealed Resident #28 was not given anything as ordered when she had gone without a bowel movement for more than three days. Interview with Resident #28 on 09/24/18 at 12:45 P.M. voiced she had problems with constipation. Interview with Licensed Practical Nurse (LPN) #94 on 09/25/18 at 5:26 P.M. confirmed Resident #28 did not have a bowel movement from 07/28/18-08/04/18, from 08/10/18-08/15/18, from 08/25/18-09/02/18 and from 09/20/18-09/24/18. She confirmed there was no evidence Resident #28 was given anything for her bowels after not having a bowel movement for more than three days. Review of the facility policy titled Bowel Management Guidelines dated 09/25/18, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 7 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few purpose is for maintaining continence and pattered bowel habits contributes to well-being. It is our goal to allow resident to maintain dignity, function at their highest continence and not experience discomfort related to bowel management. The procedure indicated that an assessment of bowel function-history of bowel patterns and current patterns; plan for bowel patterning and implement and follow up of bowel management plan. Residents will be assessed for bowel pattern change in condition with no bowel movement in three days. If a resident has not had a bowel movement in 72 hours and abnormal pattern, update the physician for orders, unless the resident has an as needed to be given. If a resident does not have a bowel movement in 24 hours update the physician for further orders. A nurse reviews a resident for ineffective bowel pattern and initiate bowel protocol as needed. Additionally, should a resident be identified with an ineffective pattern beyond the bowel protocol and not respond to nursing measures, the physician will be notified for further orders. 2. Review of Resident #11's medical record revealed an admission date of 04/15/14 with diagnoses of type two diabetes mellitus, disease of the digestive system, and ileus (inability of the bowel to contract normally and move waste out of the body). Review of the quarterly MDS dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status (BIMS) score of 15. The resident required two person extensive assist with bed mobility; extensive one person assist with transfers and an extensive one person assist with toilet use. Review of Resident #11's physician order dated 01/22/18 revealed an order for Colace (stool softener) 100 mg capsule by mouth two times a day as needed. Review of the bowel movement look back report identified Resident #11 as not having a bowel movement from 09/09/18 until 09/19/18. Review of the 09/2018 MAR revealed Resident #11 received the as needed Colace once on 09/14/18 at 9:07 A.M. Interview with Resident #11 on 09/24/18 at 10:15 A.M. voiced she goes more than three days without a bowel movement. Interview with LPN #94 on 09/26/18 at 4:21 P.M. confirmed the days Resident #11 went without a bowel movement. She confirmed the only time the resident was given something for her bowels was on 09/14/18, and she was given Colace. 3. Review of the medical record for Resident #61 revealed an admission to the facility on [DATE]. Diagnoses included open wound of the abdominal wall, pulmonary embolism, hypertension, history of urinary tract infection, history of blood disease, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic ischemic heart disease, lumbarsacral spinal stenosis, nonrheumatic aortic valve stenosis, pleural effusion and a history of transient ischemic attacks. Review of the MDS 3.0 dated 08/31/18 revealed a BIMS score of 15 indicating cognitive intactness. The MDS further revealed an unspecified open wound of the peritoneal cavity with identified surgical wound care. Review of the plan of care revealed Resident #61 was admitted with a diagnosis of small bowel obstruction with resection, abscess and fistula. Interventions included monitoring the site for redness, swelling and drainage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 8 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #61's nursing admission assessment dated [DATE] revealed there was a healed midline surgical incision with two open wounds proximal to the umbilicus measuring 3 centimeters (cm) by 1.5 cm. A distal umbilicus wound measuring 2.5 cm by 1.5 cm by 2 cm. Resident #61's medical record revealed the resident was being followed by the wound clinic at intervals. The wound was measured and wound characteristics were documented by the wound clinic. Wound clinic dates consisted of 08/14/18, 08/28/18, 09/11/18 and 09/25/18. Wound clinic notes dated 09/25/18 revealed the abdominal wound measured 1.1 cm by 1.1 cm by 1.5 cm with tunneling at 11 o'clock measuring 4.7 cm. Wound clinic documentation also described the ulcer base as containing eschar, fibrin, granulation and slough. Review of the facility weekly skin assessments dated 09/01/18, 09/10/18, 09/17/18 and 09/24/18 did not include wound measurements and/or documented wound characteristics. Observation on 09/25/18 at 1:40 P.M. of wound care for Resident #61 revealed a mid line abdominal incision with an open area with sanguineous drainage. Interview with LPN #59 on 09/25/18 at 1:40 P.M. confirmed Resident #61 had seen the wound clinic earlier on this date where the wound was measured. Review of the medical record revealed an updated physician order dated 09/26/18 for wound care and dressing changes daily consisting of cleansing the wound with normal saline, patting dry, applying Aquacel cut-in rope and cover with a dry dressing. Interview on 09/26/18 at 6:00 P.M. with LPN #94 confirmed Resident #61's medical record was silent for weekly wound measurements and wound characteristic documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 9 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to ensure weekly skin assessments and wound measurements were completed for a pressure ulcer. Additionally, the facility failed to ensure pressure ulcer treatments were completed as ordered. This affected one (Resident #28) of four residents reviewed for pressure ulcers. The facility census was 66. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of hallucinations, psychotic disorder with delusions, osteomyelitis (bone infection), multiple sclerosis (disease of the brain and spinal cord), sepsis (life-threatening complication of an infection), contracture of the left hand, type two diabetes mellitus, bipolar disorder, vascular dementia epilepsy, hypertension (high blood pressure), thrombocytopenia (low number of platelets in the blood), anxiety disorder, peripheral vascular disease (PVD), constipation, neurogenic bowel, and neuromuscular dysfunction of the bladder. Review of the significant change Minimum Data Set, dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. The resident required total dependence of two person assist with transfers; total two person assist with dressing; total dependence two person assist with toilet use and total dependence one person assist with personal hygiene. The resident had two stage three pressure ulcers and one stage four pressure ulcer that were not present upon admission. Review of the care plan for potential for further skin breakdown reveled it was related to impaired mobility related to multiple sclerosis, incontinence, diabetes mellitus, and PVD (08/18/17 pressure area to left gluteal fold and pressure areas to left medial ankle and right lateral ankle on 07/20/18). Review of the Nurse Practitioner (NP) progress notes from 06/01/18 until 07/13/18 revealed the NP note dated 06/15/18 revealed an area to the left medial foot with crusted wound with distal edge open with scant amount of serous drainage, no induration. Further review of the NP progress notes failed to identify there was any assessment or measurement of the left medial foot from the date it was discovered on 06/15/18 until 07/13/18. Review of the physician orders and the 06/2018 and 07/2018 treatment administration record (TAR) revealed on 06/07/18 there was an order for the left inner foot, small open area, cleanse with normal saline, apply PolyMem (dressing to facilitate healing, relieve pain and reduce inflammation in a unique way), hypafix tape, change daily and as needed, until healed. This order was discontinued on 06/10/18. Then on 06/11/18 there was an order for the left inner foot and right foot, outside, small open area, cleanse with normal saline, apply PolyMem, hypafix tape, change daily and as needed until healed, this was discontinued on 07/25/18. Review of the weekly skin assessment dated [DATE] failed to identify the resident as having any new skin issues. The NP note dated 07/13/18 revealed per staff, the resident had open wounds of bilateral feet. The resident had a stage three (full-thickness loss of skin, in which adipose (fat) is visible in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 10 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ulcer and granulation tissue and epibbole (rolled wound edges) are often present) pressure ulcer to the left medial foot wound with adherent slough measuring 1.9 centimeters (cm) x 1.5 cm x 0.2 cm, with yellow drainage. Additionally, the resident had a stage three pressure ulcer to her right lateral ankle wound with adherent slough and yellow drainage measuring 1.6 cm x 1.5 cm x 0.1 cm. Review of the skin/wound progress notes from 06/01/18 until 07/13/18 revealed a wound/skin progress note dated 07/13/18 that revealed the area to the left medial ankle measuring 1.9 cm x 1.5 cm x 0.2 cm, with a large amount of slough removed from the area per the NP with bright red bloody drainage. New order to cleanse area with normal saline, apply Santyl (debriding agent) to wound bed, place moist gauze in wound bed, cover with dry gauze and abdominal (ABD) pad, wrap with Kerlix and secure with tape; change daily and as needed. The area to the right lateral ankle measured 1.6 cm x 1.5 cm x 0.1 cm, slough removed with a bright red blood from debridement of the wound. Cleansed with normal saline. New order to cleanse with normal saline, apply Santyl to wound bed, then moist gauze to wound bed, cover with dry gauze, ABD pad, wrap with Kerlix and secure with tape. Offload bilateral feet with pillows and turn from side to side. Review of the physician orders and the 07/2018 TAR revealed an order for the left medial ankle and right lateral ankle, cleanse the bilateral wounds with normal saline, cover wound beds with nickel thick Santyl, moist gauze, then cover with dry gauze and ABD pad, wrap with Kerlix and secure with tape, change daily and as needed, this order was started on 07/14/18. Review of the physician's order dated 08/23/18 revealed an order for the left gluteal fold-cleanse with Dakins solution (antiseptic to cleanse wounds to prevent infection), pat dry, pack wound bed with gauze soaked in Dakins, cover with dry dressing and secure with tape two times a day. Review of the 09/2018 TAR revealed there were eight days (09/05/18 at bedtime (HS), 09/06/18 at HS, 09/10/18 at HS, 09/15/18 at HS, 09/17/18 at HS, 09/20/18 at HS, 09/22/18 in the AM, and 09/23/18 at HS) the dressing was not signed off as being completed as ordered. Interview with Licensed Practical Nurse (LPN) #94 on 09/26/18 at 4:20 P.M. confirmed on 06/15/18 the NP had indicated Resident #28 had a crusted wound with distal edge open to the left foot. LPN #94 confirmed then on 07/13/18 the NP identified a Stage 3 pressure area to Resident #28's left medial ankle and right lateral foot. Follow up interview with LPN #94 on 09/26/18 at 4:45 P.M. voiced from what she could remember the area that was observed by the NP on 06/15/18 to the left foot had appeared as a callused area. She confirmed there were treatments ordered for both the left inner foot and the right outer foot, starting on 06/11/18. However, confirmed there was no assessment and measurement of any skin impairment of these areas until 07/13/18. LPN #94 confirmed on the 07/11/18 weekly skin assessment there was no indication of any new skin issues. Follow up interview with LPN #94 on 09/26/18 at 6:13 P.M. confirmed there was no evidence Resident #28's pressure ulcer treatment was completed as ordered on the following dates: (09/05/18 at bedtime (HS), 09/06/18 at HS, 09/10/18 at HS, 09/15/18 at HS, 09/17/18 at HS, 09/20/18 at HS, 09/22/18 in the AM, and 09/23/18 at HS) Review of the facility policy and procedure titled Pressure Ulcer Prevention for At Risk Patients indicated that a complete wound assessment and documentation will be done weekly on all pressure ulcers until they are healed. The criteria to be included is the site/location, stage, size, appearance of the wound bed, surrounding skin, drainage/exudate, odor, and undermining/tunneling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 11 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview and facility policy review the facility failed to ensure splints were applied as ordered and applied correctly. This affected two residents (#28 and #53) of two reviewed for the use of splints. The facility identified eight residents as using splints. The facility census was 66. Findings include: 1. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of history of stroke, hemiplegia or hemiparesis, hypertension, diabetes and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 was cognitively impaired. Section G revealed she was totally dependent on facility staff assistance for transfers, bathing hygiene care and dressing. Review of the Plan of Care (POC) revealed Resident #53 had the potential for joint contracture related to reduced activity levels and inability to perform her own activities of daily living. Review of the physician orders dated 12/13/17 revealed resting right-hand splint on with A.M. cares, off with bedtime cares. Review of the Treatment Administration Record (TAR) from 09/01/18 to 09/26/18 revealed the right-hand splint was not been signed on 09/07/18, 09/08/18, 09/09/18, 09/12/18, 09/13/18, 09/21/18 or 09/22/18. Observation on 09/24/18 at 9:03 A.M. revealed Resident #53 was in her room in her wheelchair. She had a splint on her right-hand, but it was not correctly applied. The splint was loose and was not secured with the Velcro straps. The padded palm rest was not in the palm of her hand. Ten minutes after the observation at 9:13 A.M. two State Tested Nurse Aids (STNAs) were observed entering Resident #53's room and they closed the door. After the STNAs exited the room observation revealed Resident #53 was in bed. The splint was removed and the resident was not wearing the splint on her right hand as ordered. Review of the Behavior Symptom charting from 09/12/18 to 09/25/18 revealed Resident #53 had no behaviors of any rejection of care. There were no negative behaviors of any kind documented, including removing her brace. Observation on 09/25/18 at 2:24 P.M. revealed Resident #53 was laying in her bed. There was no splint on her right hand at this time. Interview with Licensed Practical Nurse (LPN) #58 on 09/25/18 at 2:31 P.M. verified Resident #53 was totally dependent on staff for all her care. LPN #58 verified the resident had a right-hand contracture and had an order to wear a splint on her right hand. The splint was supposed to be applied in the morning, left on all day and removed at bedtime. LPN #58 stated Resident #58 sometimes removed the splint herself. Observation on 09/26/18 at 9:18 A.M. revealed Resident #53 was again in bed. She had the splint on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 12 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her right hand but not correctly applied. The splint was strapped to her right wrist, but the right hand was not in place on the padded palm rest. Interview on 09/26/18 at 10:31 A.M. with STNA # 31 verified Resident #53 was totally dependent on staff for all her care needs. STNA #31 verified Resident #53 used the right-hand splint for a hand contracture. STNA #31 stated staff apply the splint in the morning when the resident gets out of bed and staff remove the splint when they lay the resident down after lunch. Interview with STNA #57 on 09/26/18 at 10:37 A.M. stated Resident #53 only wore the splint until after lunch. The STNA's remove the splint when they lay her down in bed after lunch. Observation on 09/26/18 at the time of the interview with STNAs #31 and #57 revealed Resident #53 had the splint on her right wrist and it was not applied correctly. STNA #31 verified Resident #53's hand was not secured in place with her fingers and palm on the padded palm rest. STNA # 31 stated the resident must have wiggled the splint off. Interview with STNA #57 on 09/26/18 at 1:37 P.M. stated the nurse educated her on the proper schedule for the splint. The splint was supposed to be on from morning until bedtime. STNA #57 verified the STNA's had not been following the ordered schedule and they had routinely removed the splint in the afternoons after lunch every day. Interview with Registered Nurse (RN) #200 on 09/26/18 at 4:12 P.M. verified the TAR was not signed and the splint was not documented as applied on eight occasions from 09/01/18 to 09/26/18. 2. Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of multiple sclerosis (disease of the brain and spinal cord) and contracture of the left hand. Review of the significant change MDS dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. The resident had a functional range of motion impairment of the upper extremities on both sides. Review of the care plan for potential for joint contractures, initiated 10/13/17 revealed the resident was to wear bilateral hands splints during the night, on with P.M. care and off with A.M. care. Review of the physician's order dated 09/17/18 revealed an order for bilateral hands splints on at bedtime and off in the morning. Observation on 09/25/18 at 8:00 A.M. revealed Resident #28 was not observed to have her bilateral hands splints in place. Additionally, there was only one hand splint observed to be in her room. Observation on 09/26/18 at 7:31 A.M. revealed Resident #28 was not observed to have her bilateral hand splints in place. Additionally, there was only one hand splint observed to be in her room. Interview with LPN #94 on 09/26/18 at 8:00 A.M. confirmed Resident #28 had an order for bilateral hand splints, they were put on at night and were taken off during the day with care. LPN #94 confirmed Resident #28 did not currently have her splints on, however, voiced the resident had already had her shower this morning. LPN #94 confirmed there was only one hand splint in the resident's room. Interview with STNA #120 on 09/26/18 at 8:05 A.M. voiced she had given Resident #28 her shower (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 13 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete already. STNA #120 confirmed Resident #28 was not wearing her hand splints when she got her up to give her a shower. STNA #120 voiced when the resident wore her hand splints, the resident only wore it to her left hand. Review of the undated facility policy titled Application of Splint/Brace Procedure revealed follow the instructions for the specific type of splint as outlined in the plan of care. Follow the written application/tightening/tolerance schedule as outlined on the plan of care. Event ID: Facility ID: 365458 If continuation sheet Page 14 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated. This affected three (#2, #39, and #61) of four residents reviewed for respiratory care. The facility identified ten residents utilizing oxygen therapy. The facility census was 66. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 09/11/18. Diagnoses included methicillin resistant staphylococcus aureus infection, bacteremia, cellulitis left upper limb, disruption of external operation surgical wound, venous insufficiency, type two diabetes mellitus, non-pressure chronic ulcer of left lower leg, history of circulatory diseases, history of urinary tract infections, acquired absence of left leg below knee, acquired absence of left toes, anemia, end stage renal disease, phosphorus metabolism disorder, hyponatremia, hypercholesterolemia, acquired absence of right toes, dependent on renal dialysis, history of pneumonia, history of malignant neoplasm of skin, morbid obesity due to excess calories, osteoarthritis, peripheral vascular disease, hyperlipidemia, chronic obstructive pulmonary disease, hereditary and idiopathic neuropathy, history of endocrine nutritional and diabetic neuropathy, osteoporosis, benign prostatic hyperplasia, disorder of bone, atrial fibrillation, obstructive sleep apnea (OSA), hypothyroidism, chronic ischemic heart disease, diseases of the musculoskeletal system and connective tissue, cataract and respiratory system diseases. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. The MDS further revealed oxygen utilization. Observation on 09/25/18 at 12:26 P.M. revealed an oxygen concentrator present in Resident #2's room. The nasal cannula tubing connected to the oxygen concentrator was undated. Interview at the time of the observation with Licensed Practical Nurse (LPN) #59 confirmed the nasal cannula oxygen tubing connected to the oxygen concentrator was undated. LPN #59 stated that the tubing was to be dated and replaced weekly. 2. Review of the medical record for Resident #39 revealed an admission date of 08/06/18. Diagnoses include sepsis of unspecified organism, heart failure, cellulitis left lower limb, bacteremia, sick sinus syndrome, dizziness, cardiomyopathy, renal dialysis dependent, osteoarthritis, neuromuscular bladder dysfunction, paroxysmal atrial fibrillation, benign prostatic hyperplasia, bradycardia, acute kidney failure, chronic kidney disease - stage four, edema, vitamin D deficiency, fluid overload, oxygen dependent, unspecified cataract, osteoarthritis left shoulder, superficial mycosis, anemia, gout, history of urinary tract infection, hypertension, emphysema, cardiac pacemaker, arthropathy, type two diabetes mellitus, atrioventricular block, atrial flutter, chronic obstructive pulmonary disease, left bundle branch block and morbid obesity. Review of the MDS dated [DATE] revealed Resident #39 was cognitively intact. The MDS further revealed oxygen utilization. Observation on 09/25/18 at 12:30 P.M. revealed an oxygen concentrator present in Resident #39's room. The nasal cannula tubing connected to the oxygen concentrator was undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 15 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview at the time of the observation with Licensed Practical Nurse (LPN) #59 confirmed the nasal cannula oxygen tubing connected to the oxygen concentrator for Resident #39 was undated. LPN #59 stated that the tubing was to be dated and replaced weekly. 3. Review of the medical record for Resident #61 revealed an admission date of 06/27/18. Diagnoses included epistaxis, urinary retention, open wound of abdominal wall, local infection of skin and subcutaneous tissue, deviated nasal septum, intestinal fistula, surgical aftercare, arthropathy, pulmonary embolism, hypertension, hypothyroidism, gastroesophageal reflux disease, hyperlipidemia, anxiety, history of urinary tract infections, history of blood disease, chronic bronchitis, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic ischemic heart disease, low back pain, lumbarsacral spinal stenosis, history of respiratory diseases, nonrheumatic aortic valve stenosis, pleural effusion and history of transient ischemic attacks. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact. The MDS further revealed oxygen utilization. Observation on 09/25/18 at 1:40 P.M. revealed an oxygen concentrator present in Resident #61's room. The nasal cannula tubing connected to the oxygen concentrator was undated. Interview at the time of the observation with Licensed Practical Nurse (LPN) #59 confirmed the nasal cannula oxygen tubing connected to the oxygen concentrator for Resident #61 was undated. LPN #59 stated that the tubing was to be dated and replaced weekly. Review of a facility provided document titled, Operational Policy and Procedures - Respiratory Services dated 05/14/15 indicated its purpose was to provide caregivers a recommended guideline for changing disposable medical equipment for infection control purposes. Oxygen cannula's are to be changed on a weekly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 16 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 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 and staff interview the facility failed to ensure ear drops were administered as ordered. This affected one (Resident #28) of one reviewed for hearing. The facility census was 66. Findings include: Review of Resident #28's medical record revealed an admission date of 07/16/15 with diagnoses of hallucinations, psychotic disorder with delusions, multiple sclerosis, type two diabetes mellitus, bipolar disorder, vascular dementia, epilepsy, hypertension, anxiety disorder. Review of the significant change Minimum Data Set, dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status score of 15. Review of the physician order dated 09/14/18 at 2:14 P.M. revealed Debrox Solution (for the use of removal of ear wax), instill five drops in left ear one time a day for cerumen build up, for five days. Review of the 09/2018 medication administration record revealed (MAR) revealed the medication was ordered to start on 09/14/18 at bedtime. The medication was signed off as not being available on 09/14/18. The medication was signed off as only being administered for four days (09/15/18-09/18/18). Interview with Licensed Practical Nurse (LPN) #94 on 09/25/18 at 5:58 P.M. confirmed the ear drops were ordered on 09/14/18, and were ordered to be started on 09/14/18, however they were unavailable. She confirmed the resident only received four days of ear drops. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 17 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to ensure residents who were prescribed as needed (PRN) psychotropic days were limited to 14 days. This affected two Residents (#7 and #61) of six residents reviewed for unnecessary medications. The facility identified 42 residents who received psychotropic medications. The census was 66. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia with behavioral disturbance, bipolar disorder, schizoaffective disorder, eating disorder, hypertension, major depressive disorder, hyperlipidemia, history of urinary tract infections, aphasia, history of malignant neoplasm of the ovary, history of blood diseases and blood forming organs and disorders involving the immune system, cardiac arrhythmia, history of transient ischemic attacks and psychotic disorder with delusions due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment. The MDS further indicated the resident had received antipsychotic and antidepressant medications on a routine basis with a contraindicated gradual dose reduction documented on 05/04/18. Review of the physician orders dated 07/28/18 revealed Resident #7 was prescribed Alprazolam (anti-anxiety medication) 0.25 milligram (mg) tablet, administer by mouth every six hours PRN for anxiety, agitation. Review of Medication Administration Records (MAR) for 07/2018 revealed Alprazolam 0.25 mg was administered on 07/30/18 at 1:15 P.M. Review of the MAR for 08/2018 revealed Alprazolam 0.25 mg was administered on 08/30/18 at 5:53 P.M. Review of the 09/2018 MAR revealed Alprazolam 0.25 mg was administered on 09/19/18 at 6:42 P.M., on 09/20/18 at 2:25 A.M., on 09/21/18 at 8:20 A.M. and on 09/24/18 at 2:58 A.M. Review of the pharmacy medication regimen review dated 08/30/18 revealed no recommendations from the pharmacist regarding the Alprazolam PRN order. Further review of the medical record for Resident #7 revealed no physician documentation specifying the continuation of the PRN Alprazolam. Interview with the Director of Nursing (DON) on 09/27/18 at 9:10 A.M. verified the PRN Alprazolam was written as a PRN order on 07/28/18. The DON further verified Resident #7's medical record did not include specifications regarding the Alprazolam PRN order. 2. Review of the medical record for Resident #61 revealed an admission date of 06/27/18. Diagnoses included epistaxis, urinary retention, open wound of abdominal wall, local infection of skin and subcutaneous tissue, deviated nasal septum, intestinal fistula, surgical aftercare, arthropathy, pulmonary embolism, hypertension, hypothyroidism, gastroesophageal reflux disease, hyperlipidemia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 18 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0758 Level of Harm - Minimal harm or potential for actual harm anxiety, history of urinary tract infections, history of blood disease, chronic bronchitis, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic ischemic heart disease, low back pain, lumbarsacral spinal stenosis, history of respiratory diseases, nonrheumatic aortic valve stenosis, pleural effusion and history of transient ischemic attacks. Residents Affected - Few Review of the MDS dated [DATE] revealed Resident #61 was cognitively intact. Review of the physician orders dated 07/06/18 revealed Resident #61 was prescribed Alprazolam 0.25 mg tablet, administer by mouth every six hours PRN for anxiety. Review of the MAR for 09/2018 revealed Alprazolam 0.25 mg was administered on 09/01/18 at 6:29 P.M., on 09/02/18 at 6:25 P.M., on 09/03/18 at 6:59 P.M., on 09/04/18 at 6:18 P.M., on 09/05/18 at 6:41 P.M., on 09/07/18 at 5:33 P.M., on 09/08/18 at 7:24 P.M., on 09/09/18 at 6:16 P.M., on 09/11/18 at 7:10 P.M., on 09/12/18 at 7:51 P.M., on 09/13/18 at 4:57 P.M., on 09/14/18 at 6:31 P.M., on 09/15/18 at 7:28 P.M., on 09/16/18 at 7:26 P.M., on 09/17/18 at 6:33 P.M., on 09/18/18 at 6:52 P.M., on 09/19/18 at 5:44 P.M., on 09/20/18 at 6:50 P.M., on 09/21/18 at 6:26 P.M., on 09/22/18 at 5:57 P.M., on 09/23/18 at 6:21 P.M., on 09/24/18 at 7:11 P.M. and on 09/25/18 at 7:32 P.M. Further review of the pharmacy medication regimen review dated 08/30/18 revealed no recommendations from the pharmacist regarding the Alprazolam PRN order. Review of the medical record for Resident #61 revealed no physician documentation specifying the continuation of the PRN Alprazolam. Interview with the Director of Nursing (DON) on 09/27/18 at 9:10 A.M. verified the PRN Alprazolam was written as a PRN order on 07/06/18. The DON further verified Resident #61's medical record did not include specifications regarding the Alprazolam PRN order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 19 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0759 Ensure medication error rates are not 5 percent or greater. 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, interview, manufacturer's instructions and facility policy review, the facility failed to maintain a medication error rate below five percent. This affected one Resident (#16) of four residents observed for medication administration. There were two medication errors of 25 observed opportunities for a medication error rate of eight percent. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE] with diagnoses of diabetes and dementia. Review of the physician orders dated 09/18/18 revealed she had an order for Toujeo SoloStar Solution Pen-injector (Insulin Glargine), inject as per sliding scale if blood glucose is 0 - 99 give zero units. If 100 - 500 give 66 units subcutaneously one time a day. Review of physcian order dated 12/28/16 revealed Rivastigmine Patch 24 Hour 9.5 milligrams (mg) in 24 hours. Apply one patch transdermally one time a day. Remove the old patch with the application of the next patch. Observation of medication administration on 09/25/18 at 6:44 A.M. with Licensed Practical Nurse (LPN) #58 revealed when LPN #58 was administering the Rivastigmine patch to Resident #16, Resident #16 had two old Rivastigmine patches still applied. One on her right upper chest and one on her left upper chest. LPN #16 removed the two old patches and applied the new patch on Resident #16's left upper chest. LPN #58 then proceeded to prepare Toujeo insulin per Pen-injector. LPN #58 obtained the Toujeo pen form the medication cart, dialed the dose of 66 units, then applied the needle. LPN #58 returned to Resident #16's room, cleansed her lower abdomen and injected the Toujeo needle, depressed the administration button to inject the insulin, then immediately removed the needle after the button was fully depressed. Interview with LPN #58 at the time of the observation verified Resident #16 had two old Rivastigmine chest left on her chest. LPN #58 verified the old patches were to be removed each time a new patch was applied and there should have only been one patch on her at the time of the application. Further LPN #58 verified she did not prime the needle of the Toujeo insulin prior to administering the injection. LPN #58 also verified she did not hold the needle in for a count of five. Review of the Toujeo insulin manufacturer's Instructions for Use revealed when using the Toujeo Pen injector to administer insulin the user should apply the needle to the pen, select three units by turning the dose selector until the dose pointer is between the two and the four. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly. Turn the dose selector until the dose pointer lines up with your dose. Push the needle into the skin in the chosen injection site. Place your thumb on the injection button. Press all the way in and hold. Keep the injection button held in and when you see 0 in the dose window, slowly count to five. This will make sure you get your full dose. Review of the facility policy titled Specific Medication Administration Procedures dated 10/22/07 revealed for transdermal drug delivery patch application, identify the location on the body for placement. Remove the old patch from the body prior to application of the new patch. Document the placement site in the medication administration record. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 20 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0760 Ensure that residents are free from significant medication errors. 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, interview, and manufacturer's instructions review, the facility failed to ensure residents received insulin with a Pen-Injector correctly. This affected one Resident (#16) of four residents observed for medication administration. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #16 revealed she was admitted to the facility on [DATE] with diagnoses of diabetes and dementia. Review of the physician orders dated 09/18/18 revealed she had an order for Toujeo SoloStar Solution Pen-injector (Insulin Glargine), inject as per sliding scale if blood glucose is 0 - 99 give zero units. If 100 - 500 give 66 units subcutaneously one time a day. Observation of medication administration on 09/25/18 at 6:44 A.M. with Licensed Practical Nurse (LPN) #58 revealed LPN #58 obtained the Toujeo pen form the medication cart, dialed the dose of 66 units, then applied the needle. LPN #58 returned to Resident #16's room, cleansed her lower abdomen and injected the Toujeo needle, depressed the administration button to inject the insulin, then immediately removed the needle after the button was fully depressed. Interview with LPN #58 at the time of the observation verified she did not prime the needle of the Toujeo insulin prior to administering the injection. LPN #58 also verified she did not hold the needle in for a count of five. Review of the Toujeo insulin manufacturer's Instructions for Use revealed when using the Toujeo Pen injector to administer insulin the user should apply the needle to the pen, select three units by turning the dose selector until the dose pointer is between the two and the four. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly. Turn the dose selector until the dose pointer lines up with your dose. Push the needle into the skin in the chosen injection site. Place your thumb on the injection button. Press all the way in and hold. Keep the injection button held in and when you see 0 in the dose window, slowly count to five. This will make sure you get your full dose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 21 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0790 Provide routine and 24-hour emergency dental care 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, interview and facility policy review the facility failed to timely schedule a dental appointment. This affected one Resident (#64) of one reviewed for dental pain. The facility identified eleven residents as receiving dental services from an outside provider. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of hypertension, wound infection, diabetes and seizure disorder. Review of the Minimum Data Set (MDS) dated [DATE], Section L, revealed Resident #64 did not have any obvious broken natural teeth and she was not experiencing any mouth or facial pain at the time of the assessment. Review of the face sheet revealed Resident #64 was a Medicare recipient with Part A, B and D and had secondary co-insurance. Review of the Physician Note dated 09/18/18 at 11:07 A.M. revealed Resident #64 asked to see the physician. She had developed a cough and congestion. She also was having some tooth pain on the left side of her mouth. She had a tooth that has broken off in the upper left molar area. She would like to see the dentist. The physician assessment was sinusitis and tooth pain. The physician plan was to start an oral antibiotic (Keflex 500 milligrams (mg), three times a day for ten days), cough syrup (Robitussin), allergy medication (Loratidine) and dental appointment for Resident #64. Review of the physician orders revealed Keflex capsule 500 mg, give by mouth three times a day for sinus infection/tooth pain for ten days ordered 09/18/18 to 09/28/18. Review of the Plan of Care revealed Resident #64 was started on an antibiotic for the treatment of sinus infection and tooth ache with a goal that she would have no signs or symptoms of infection with interventions to administer antibiotics as ordered, encourage fluids, obtain labs or cultures as ordered and monitor for pain and increased temperature as needed. Interview with Resident #64 on 09/24/18 at 10:58 A.M., she stated she had two broken teeth, one on the top left and one on the top right. Resident #64 stated her teeth were painful last week but it was feeling better now. She verified that she had spoken with the physician about her tooth pain and she needed a dental appointment to get her teeth fixed. She verified she had not yet seen the dentist for the tooth pain and stated no one had informed her of any pending dental appointment. Resident #64 also verified she was on an antibiotic since 'last week.' Interview with Registered Nurse (RN) #200 on 09/26/18 at 12:36 P.M., verified Resident #64 was on Keflex for possible sinusitis or an infected tooth. Interview with Director of Social Services (SW) #210 on 09/26/18 at 12:42 P.M., verified she took care of scheduling dental appointments. SW #210 verified she was aware Resident #64 needed to be seen by the dentist related to her left upper tooth pain, that she had a broken a tooth and the physician ordered a dental appointment. SW #210 stated she checked to see when the facility dentist was coming again and it would be a month or more before the facility dentist would see her. SW #210 later verified Resident #64 had not selected facility provided dental services. SW #210 verified Resident #64 was a Medicare recipient with private insurance and still received dental services with her own dentist and this meant Resident #64 would not be seen by the facility dentist. SW #210 verified she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 22 of 23 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 365458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wood Haven Health Care Senior Living & Rehab 1965 E Gypsy Lane 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 0790 had not yet made any attempt to schedule a dental appointment for Resident #64. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 09/26/18 at 4:33 P.M., verified there was no dental appointment scheduled for Resident #64. The DON verified Resident #64 did not sign consent to see the facility dentist and still received private dental care. Residents Affected - Few Review of the facility policy titled Dental Service Policies dated August 2017 revealed the purpose was to provide all resident with access to dental care and services. Routine dental care was provided. The Dental Service will be responsible for providing services that come to the facility and/or outside provider. The resident's dentist will be determined at the time of admission and reflected in the resident's clinical record. When necessary transportation to and from the dentist office will be arranged by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365458 If continuation sheet Page 23 of 23