Inspection·August 24, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to reassess the effectiveness of interventions and failed to review and update the comprehensive care plan for a resident. This affected one (Resident #53) of 22 residents whose care plans were reviewed. The facility census was 64. Findings include: Resident #53 was admitted on [DATE] with diagnoses including diabetes mellitus type II, acute kidney failure, displaced intertrochanteric left femur fracture, hypertension, depression, morbid obesity, osteoarthritis, and iron deficiency. Review of the Minimum Data Set (MDS) assessment, dated 07/15/22, revealed Resident #53 had moderate cognitive impairment. Resident #53 required extensive assistance for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene and required the assistance of two personal for bathing. Resident #53 was independent with eating. Review of the physician order dated 04/10/22 revealed a regular diet with mechanical soft ground meats. A physician order dated 07/19/22 added a magic cup two times a day, four ounces to be served with lunch and dinner at the recommendation of the dietician. Review of weights for Resident #53 revealed a preadmission weight from the hospital history and physical of 249.7 pounds on 12/29/21. Review of the facility weight for Resident #53 revealed a weight of 253 pounds on 03/05/22, a weight of 191 pounds on 04/05/22, a weight of 176.8 pounds on 06/05/22, a weight of 162.2 pounds on 07/15/22 and a weight of 157 pounds on 08/16/22. Resident #53 was reweighed by the Director of Nursing on 08/18/22 at 1:37 P.M. revealed a weight of 150.6 pounds. Review of the percentage of meals consumed from 07/24/22 through 08/18/22 revealed on average for breakfast fifty-one to one hundred percent of the meal is consumed with breakfast refused on 08/02/22 and 08/12/22. For lunch, on average fifty-one to one hundred percent of the meal is consumed, Resident #53 refused lunch on 08/02/22 and 08/13/22. For dinner, on average fifty-one to seventy-five percent of the meal is consumed and on average seventy-six to one hundred percent of the time the bedtime snack is consumed. The bedtime snack was refused on 08/05/22 and 08/17/22. Review of the care plan dated 02/23/22 for Resident #53 stated Resident #53 would not have significant with loss and an intervention to report any significant weight changes to the dietician, physician, and family. The care plan contained no documentation of interventions or updates related to Resident #53's weight loss. Interview with the Registered Dietician #439 on 08/17/22 at 3:20 P.M. revealed lack of knowledge related to Resident #53's significant weight loss. Registered Dietician #439 stated she will need to investigate. Interview with the Director of Nursing on 08/18/22 at 1:37 P.M. revealed lack of knowledge related to the weight loss for Resident #53. Review of the policy titled Documentation: Charting, undated, revealed the purpose of information (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 2 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0657 in the clinical record is to provide a means of communication between physician, and other professionals contributing to the resident's care, and is a basis for planning and providing care to each resident. 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: 365489 If continuation sheet Page 3 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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, interview and policy review, the facility failed to provide showers for residents dependent on staff for activities of daily living. This affected six (Residents #36, #41, #45, #60, #64 and #20) of six residents reviewed for showers and baths. The census was 67. Residents Affected - Some 1. Review of Resident #36's medical record revealed an admission date of 06/27/22. Diagnosis included peripheral vascular disease, chronic kidney disease, prostate cancer, and atherosclerosis. Review of Resident #36's admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed the resident had a moderate cognitive function. The resident required an extensive assist of one person for personal hygiene, bathing, and dressing. Review of Resident #36's most recent care plan revealed the resident had an activity of daily living self-care performance deficit related to chronic kidney disease, fluctuating activities of daily living, and generalized weakness. During an interview on 08/15/22 at 10:05 A.M., Resident #36 stated he did not receive showers or baths timely and he had to ask to receive them. The resident also stated he would have liked to have his fingernails cut, but no staff would complete the task. Review of the facility shower and bath schedule revealed Resident #36 was scheduled to have a shower or bath every Monday and Saturday on day shift. Review of Resident #36's shower documentation revealed the resident had a shower on 06/29/22 and was not given another bath or shower for seven days, until 07/06/22. The resident received a bed bath on 07/09/22, 07/13/22, a shower on 07/20/22 which was once a week. A bed bath was received on 07/27/22 and the next bed bath was not received until 08/03/22. Review of Resident #36's nursing notes dated 06/27/22 through 08/17/22 revealed no information related to refusal of baths or showers. Observation of Resident #36 on 08/15/22 at 10:04 A.M. revealed the resident was disheveled looking with uncombed hair and long fingernails. 2. Review of Resident #41's medical record revealed an admission date of 09/01/18. Diagnosis included traumatic brain injury, muscle wasting and atrophy, schizoaffective disorder, spastic hemiplegia affecting the left side, ataxia, and dysarthria and anarthria. Review of Resident #41's quarterly MDS assessment, dated 07/01/22, revealed the resident had high cognitive function. Review of Resident #41's most recent care plan revealed staff were to assist the resident with activities of daily living (i.e.: dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. Interview with Resident #41 on 08/15/22 at 10:16 A.M. revealed he would like his nails trimmed and had asked staff in the past, but the task was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 4 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility Shower Schedule revealed the resident was to have a shower every Tuesday and Friday on the evening shift. Review of Resident #41's shower documentation revealed the resident received a shower on 05/09/22 and not again until 05/17/22. A shower was received on 05/19/22 and the next one was on 05/26/22. It was 24 days later on 06/20/22 when the resident received his next shower. After receiving a shower on 06/23/22 the next shower was given on 07/14/22. A shower was offered on 07/18/22 which was documented as refused and the staff offered the next shower on 07/25/22 and on 08/11/22 thereafter. The STNA noted that the resident's nails did not need clipped. Review of nursing notes dated 05/09/22 through 08/16/22 revealed no notes regarding the resident refusing showers. Observation of Resident #41 on 08/15/22 at 10:14 A.M. revealed the resident had long, dirty fingernails and his hair was disheveled. At 1:22 P.M. the resident was observed in his room sitting in a wheel chair with food on his chin and shirt. Observations on 08/16/22 at 2:01 P.M. revealed Resident #41 had food on his pants from lunch. In addition, when the had taken off his face mask to speak and a large area of yellow substance was seen inside the mask. 3. Review of Resident #45's medical record revealed an admission date of 06/24/20. Diagnosis included chronic kidney disease, tremors, lung cancer, alcohol dependence, chronic respiratory failure, and hip replacement. Review of Resident #45's quarterly MDS assessment, dated 07/08/22, revealed the resident had a high cognitive function and required an extensive one person assist for personal hygiene, dressing, toilet use, and bathing. Review of Resident #45's most recent care plan revealed the resident has an ADL self-care performance deficit related to anxiety, chronic obstructive pulmonary disease, and depression. He required assistance with activities of daily living which included dressing, grooming, personal hygiene, and oral care. Interview with Resident #45 on 08/16/22 at 9:44 A.M. revealed his last shower was three weeks ago. He stated it depended on which STNA was working if he would get assistance. Some STNA's would give showers/bathes and others would not and no one would even bring him a washcloth in the morning. Review of the facility shower schedule revealed Resident #45 was scheduled to have showers every Wednesday and Saturday on the day shift. Review of Resident #45's shower documentation revealed the resident received a shower on 06/18/22, 06/29/22 and 08/06/22. Review of nursing notes dated 05/25/22 through 08/17/22 revealed no refusal of showers/bathes. Observation of Resident #45 on 08/15/22 at 11:22 A.M. revealed the resident was disheveled with greasy hair and an unshaven face. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 5 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of Resident #60's medical record revealed an admission date of 2021. Diagnosis included congestive heart failure, urinary retention, chronic gout of the left ankle and foot, morbid obesity, and bladder cancer. Review of Resident #60's quarterly MDS assessment, dated 07/21/22, revealed the resident had a high cognitive function. He required a two person extensive assistance for bed mobility, transfers, personal hygiene, and bathing. Review of Resident #60's most recent care plan revealed the resident had an activity of daily living self-care performance deficit related to depression, fluctuating activity of daily living, functional limitation in range of motion, generalized weakness, history of falls, impaired mobility, pain, and a history of a hip fracture. Interventions were to assist with activities of daily living such as personal hygiene, oral care and grooming. Interview with Resident #60 was completed on 08/15/22 at 10:37 A.M. The resident stated he had to ask for a sponge bath, but hadn't received one in a month. Review of facility shower schedule revealed Resident #60 was scheduled to receive a shower on day shift every Monday and Thursday. Review of Resident #60's shower documentation revealed the resident received a shower on 05/05/22 and it wasn't until 18 days later, on 05/23/22 when he received the next shower. Twenty four days later he received a shower on 06/16/22, then two weeks later on 6/30/22. The last shower was received seven days later on 07/07/22 then on 07/14/22. On 08/01/22 a shower/bed bath was received and then 10 days later on 08/11/22. 5. Review of Resident #64's medical record revealed an admission date of 07/21/22. Diagnosis included osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer, paraplegia, spina bifida, and morbid obesity. Review of Resident #64's admission MDS assessment, dated 07/28/22, revealed he had a high cognitive function. The resident required an extensive assist of 2 staff for bed mobility, dressing, and personal hygiene. Review of Resident #64's most recent care plan revealed he resident had an ADL self-care performance deficit related to impaired mobility, obesity, and paraplegia. Interview with Resident #64 on 08/15/22 at 10:51 A.M. revealed he had not had a bath or shower since admitted on [DATE] but once in a while they would wipe him off with a wash cloth. Review of the facility shower schedule revealed Resident #64 was to be given a shower every Wednesday and Saturday nights. Review of Resident #64's shower documentation revealed the resident had a bed bath on 07/23/22, 07/27/22 and then not again until 08/06/22. Observation on 08/15/22 at 10:43 A.M. revealed Resident #64 was laying in bed with uncombed hair and beard growth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 6 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with STNA's #300, #335, and #420 on 08/17/22 between 9:10 A.M. and 3:18 P.M. revealed the staff attempted to complete all showers timely, but if they could not get completed the next shift was informed and the showers were to be completed then. 6. Resident #20 was admitted to the facility originally on 06/10/22. He was discharged and then readmitted on [DATE]. His admitting diagnoses included metabolic encephalopathy, asthma, heart failure, carcinoma insitu of prostate, tachycardia, atrial fibrillation and overactive bladder. Review of the MDS assessment, dated 08/08/22, revealed this resident was alert and oriented times three. Functionally, he needed extensive assistance of one to two people for a majority of activities of daily living including transfers, dressing, toilet use and personal hygiene. During interview on 06/17/22 at 3:45 P.M., Resident #20 revealed he just received a shower on 08/16/22. Before that he can't remember when he had one. He thinks it was when he was first admitted back in June He stated the aid informed him that he is suppose to get his showers on Tuesdays and Thursdays. Interview with STNA #420 on 08/17/22 at 4:06 P.M. revealed this resident gets his showers on Tuesdays and Fridays in the morning. Review of the resident's shower documentation revealed this resident did not receive a shower as per his plan of care on 07/08, 07/12, 07/15, 07/22, 07/26, and 08/09/22. During interview on 08/17/22 at 4:06 P.M., STNA #420 verified that if a resident does receive a shower then he would have a shower sheet. When asked about no showers for the above listed dates she stated then he must have not gotten a shower or refused it. Review of the facility policy titled Shower/Tub Bath, undated, revealed the purpose of the shower/bath was to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. The staff were to notify the supervisor if the resident refused the shower/tub bath. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 7 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and policy review, the facility failed to ensure an indwelling urinary catheter was maintained to prevent infection. This affected one (Resident #44) of one resident reviewed for catheter care. The census was 65. Findings include: Review of Resident #44's medical record revealed an admission date of 06/27/22. Diagnosis included infection and inflammatory reaction due to indwelling urethral catheter, dysphasia, Huntington's disease, gout, and diabetes mellitus. Review of Resident #44's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive function. The resident had an indwelling catheter and was always continent of bowel. Review of Resident #44's most recent care plan revealed the resident had a need for an indwelling catheter related to acute urinary retention due to benign prostatic hypertension. Catheter care was required each shift. Review of Resident #44's medical record revealed a physician's order dated 07/03/22 for the catheter to be to continuous drainage and to monitor output every shift. Review of Resident #44's Treatment Administration Record (TAR) dated July 2022 reveal the facility failed to monitor the resident's urinary output as ordered on 07/04/22, 07/06/22, 07/08/22, 07/09/22, 07/13/22, 07/18/22, and 07/22/22 on the day shift and on 07/06/22, 07/09/22, 07/18/22, and 07/21/22 on the night shift. Review of the resident's TAR dated August 2022 revealed urinary output failed to be documented on 08/01/22, 08/02/22 on the day shift and on 08/05/22, 08/10/22, 08/12/22, and 08/14/22 on the night shift. Observation of Resident #44 on 08/16/22 at 12:11 P.M., revealed the resident was lying in bed. His Foley catheter bag was observed laying on the floor at his bedside. The resident had multiple contractures and was unable to get out of bed on his own. Interview with State Tested Nursing Aide (STNA) #420 on 08/16/22 at 12:15 P.M. verified Resident #44's Foley bag was laying on the floor which was an infection control issue. Observation of Resident #44 on 08/16/22 at 2:02 P.M. revealed the resident was in bed and his Foley catheter bag was laying on the floor at bedside. Interview with STNA #432 on 08/16/22 at 2:02 P.M. verified Resident #44's Foley catheter bag remained on the floor at bedside. During observation on 08/17/22 at 8:15 A.M., Resident #44's catheter drainage bag was full and unable to hold any more urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 8 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During interview on 08/17/22 at 8:22 A.M., State Tested Nursing Assistant (STNA ) #420 stated the catheter bag was not emptied by the night shift staff and she had not had time to empty the bag. The bag was to be emptied and the urine amount was then reported to the nurse to be documented. Interview with Clinical Program Specialist #438 on 08/18/22 at 12:29 P.M. revealed the facility did not have a policy related to indwelling urinary catheter care. Event ID: Facility ID: 365489 If continuation sheet Page 9 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 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 record review, observation, interview and policy review, the facility failed to ensure a resident who required dialysis was receiving the care and treatment according to physician orders and failed to maintain communication with the dialysis center on coordination of care. This affected one (Resident #61) of one resident reviewed for dialysis. The facility census was 65. Residents Affected - Few Findings include: Review of Resident #61's medical record revealed an admission date of 07/16/22, with diagnoses that included: end stage renal disease, morbid obesity, chronic obstructive pulmonary disease, atrial fibrillation, hyperkalemia, congestive heart failure, diabetes mellitus, type II, anemia, and hypertension. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #61 was cognitively intact, had clear speech and was able to understand others and able to make self-understood. Resident #61 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene and required total dependence for transfers. Resident #61 was occasionally incontinent of urine and was dependent on renal dialysis. Review of the physician orders revealed an order dated 07/16/22 for renal dialysis three times a week on Mondays, Wednesday, and Fridays at 11:30 A.M., an order for daily weights written on 07/17/22 and on 07/18/22 an diet order for a fluid restriction 1000 milliliters (ml) in 24 hours. The fluid restriction specified 600 ml on dietary trays with 240 ml provided at breakfast, 120 ml provided at lunch, and 240 ml provided at dinner. Nursing was allowed 400 ml per day, 200 ml during the day, 150 ml in the evening and 50 ml at bedtime. Review of the care plan dated 07/16/22 revealed an impaired genitourinary status with interventions that included to complete daily weights, diet as ordered and to notify the physician if non-compliant with fluid restriction. Review of the intake record for Resident #61 revealed incomplete documentation of fluid intake for the 24-hour time frame on 07/18/22, 07/19/22, 07/20/22, 07/21/22, 07/22/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, 07/27/22, 07/28/22, 07/29/22, 07/30/22, 07/31/22, 08/01/22, 08/02/22, 08/03/22, 08/05/22, 08/06/22, 08/07/22, 08/08/22, 08/09/22, 08/10/22, 08/11/22, 08/12/22, 08/15/22, 08/16/22, and 08/17/22. Review of the documentation for daily weights revealed no weights were obtained for Resident #61 on 07/21/22, 07/22/22, 07/23/22, 07/27/22, 07/29/22, 08/01/22, 08/03/22, 08/07/22, 08/08/22, 08/10/22, 08/12/22, 08/13/22, 08/14/22 and 08/15/22. Review of the progress notes for Resident #61 revealed a nurse's note dated 07/28/22, the dialysis center recommended medication adjustments. Licensed Practical Nurse (LPN) #318 stated the medication list at dialysis center did not coincide with the facilities. Review of progress note dated 08/11/22 revealed the resident stated the dialysis machine on 08/10/22 was broken so they were note able to get any fluids off. LPN #333 was unable to find the dialysis paperwork to confirm the communication from the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 10 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of dialysis communication sheets was silent for pre or post dialysis treatment communication between the facility and the dialysis center on 07/10/22, 07/22/22, 08/01/22, 08/03/22, 08/05/22, 08/10/22, 08/12/22, and 08/15/22. Interview with Resident #61 on 08/16/22 at 2:44 P.M. confirmed the lack of communication between the facility and the dialysis center. Resident #61 stated she is the one doing the communication. Observation on 08/17/22 at 8:38 A.M., revealed an open, quarter empty bottle of soda on Resident #61's over bed table. Interview at the time of the observation with Licensed Practical Nurse (LPN) #425 verified the resident had a partial bottle of soda. Interview with Registered Nurse (RN) #438 on 08/17/22 at 11:11 A.M. verified there was no pre or post dialysis treatment communication between the facility and or the dialysis center on 07/10/22, 07/22/22, 08/01/22, 08/03/22, 08/05/22, 08/10/22, 08/12/22, and 08/15/22. RN #438 stated the documentation of the intake with meals is recorded by the aides and all other intake is recorded by the nurses. RN #438 verified the intakes are not recorded consistently for Resident #61 and further verified the fluid restriction as ordered has not been followed. Interview with LPN #425 on 08/17/22 at 10:55 A.M. verified the only resident on a fluid restriction is Resident #61 and further verified there are days when the intake for Resident #61 had not been recorded. LPN #425 further verified the fluid restriction for Resident #61 had not been followed. Interview on 08/17/22 at 3:10 P.M. with Registered Dietician #439 revealed lack of knowledge the fluid restriction for Resident #61 was not being followed. Review of the updated policy titled Hydration Intake and or Urine Output is required to accurately determine the amount of liquid a resident consumes in a twenty-four-hour period. A physician order is needed, and the special need of the resident is to be addressed in the care plan. Review of the undated policy titled Documentation: Charting revealed the information on the record is meant to provide a means of communication between the physician and other professionals on the care team and is a basis for planning care and treatment. Review of the undated policy titled Dialysis revealed the facility will communicate before and after dialysis and coordinate care as needed. This deficiency substantiates Complaint Number OH000134514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 11 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on employee file review, staff interview, and policy review, the facility failed to complete annual evaluations on State Tested Nursing Aides (STNA). This affected four (#322, #327, #420, #424) of four STNA employee files reviewed. This had the potential to affect all 65 residents. The facility census was 65. Residents Affected - Some Findings include: Review of STNA #322's employee file revealed a hire date of 04/22/14. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #327's employee file revealed a hire date of 07/03/19. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #420's employee file revealed a hire date of 01/25/05. The employee file did not contain a yearly employee evaluation for the past 12 months. Review of STNA #424's employee file revealed a hire date of 12/05/18. The employee file did not contain a yearly employee evaluation for the past 12 months. Interview on 08/18/22 at 9:16 A.M., with the Director of Nursing verified STNAs, #322, #327, #420, and #424 failed to have their annual performance evaluations completed. Review of the policy titled Performance Evaluations dated 09/2021, revealed the job performance of each employee shall be reviewed and evaluated at least annually. The completed performance evaluation will be sent by the director or supervisor to the human resource director to be placed in the employee's personnel record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 12 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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, resident council minutes review, resident and staff interviews, the facility failed to serve hot and palatable foods. This had the potential to affect 65 of 65 residents who receive food from the kitchen. The facility census was 65. Residents Affected - Many Findings include: Interview with Resident #21 on 08/15/22 at 3:48 P.M., revealed the food was horrible, cold and not at all appetizing. Interview with Resident #24 on 08/15/22 at 11:41 A.M., revealed the food was cold and not palatable. Interview with Resident #33 on 08/15/22 at 10:27 A.M., revealed the was food cold and there is no variety. Interview with Resident #60 on 08/15/22 at 10:33 A.M., revealed the food was cold and terrible. He stated he would send the food back to be reheated but would be cold again by the time the staff brought it back. Resident #60 stated the facility used to give out a monthly menu, but they discontinued to do so. The menu failed to be followed when it was distributed. Interview with Resident #64 on 08/15/22 at 10:50 A.M., revealed all meals were served cold and were not palatable. Review of the test tray with Kitchen Manager #437 on 08/16/22 at 12:41 P.M., revealed the tray consisted of ham and beans, corn bread, spinach, roasted potatoes, and cheesecake. The ham and beans were soft and tender and with good flavor and was noted to be barely warm and measured a temperature of 112 degrees Fahrenheit (F). The spinach was noted to be bland and barely warm with little to no seasoning and measured a temperature of 98 degrees F. The roasted potatoes were firm and strongly seasoned and measured a temperature of 98 degrees F. The cornbread was soft and crumbled in hands making it difficult to eat and or to check the temperature. The cheesecake was tender and sweet with a temperature of 78 degrees F. Kitchen Manager #437 verified the findings of the test tray at the time of observation. Interview with Kitchen Manager #437 during the test tray observation revealed any hot food should be served above 140 degrees F. Reviewed of Resident Council meeting minutes dated 06/21/22 and 07/19/22 revealed concerns regarding food service and the dining experience. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 13 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment in the kitchen. This has the potential to affect 65 of 65 residents receiving food and drink from the kitchen and who reside in the facility. The census was 65. Findings include: Observation on 08/16/22 between 9:27 A.M. and 10:00 A.M., of the kitchen, with Kitchen Manager #437 revealed: the box refrigerator with cartons of milk contained a white frosty substance halfway down all four sides of the walls of the refrigerator. The white substance flaked off the side walls and fell to the bottom of the refrigerator. The ceiling above the serving station and the lights above the stove and steam table contained dust and dirt. The water dispensing silver colored valve contained a quarter inch long black substance. Interview, at the time of the observation, with Kitchen Manager #437 revealed uncertainty of the last time the water dispensing machine machine was cleaned. Kitchen Manager #437 removed the substance from the dispenser and the black, slimy substance smeared in the paper towel. Further interview verified the dirty lights and the cartons of milk had unidentified substances on them and the refrigerator. Interview on 08/16/22 at 4:30 P.M., with the Director of Environmental Services #400, revealed the inside of the water dispensing machine had been cleaned monthly, adding the water dispenser is not specifically outlined in the cleaning process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 14 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure accurate and complete medical records were maintained. This affected one (Resident #61) of 22 resident records reviewed. The facility census was 65. Findings include: Review of Resident #61's medical record revealed an admission date of 07/16/22, with diagnoses that included: end stage renal disease, morbid obesity, chronic obstructive pulmonary disease, atrial fibrillation, hyperkalemia, congestive heart failure, diabetes mellitus, type II, anemia, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE], Resident #61 was cognitively intact, had clear speech and was able to understand others and able to make self-understood. Resident #61 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene and required total dependence for transfers. Resident #61 was occasionally incontinent of urine and was dependent on renal dialysis. Review of physician orders revealed an order for a glycated hemoglobin test (HgbA1C) every three months. Review of laboratory tests for Resident #61 revealed a HgbA1C was completed and resulted on 08/08/22. Review of the treatment record for August 2022 revealed the order for the HbgA1C has been signed off every day between 08/01/22 and 08/16/22. Interview on 08/17/22 at 3:52 P.M., with the Director of Nursing #337 verified the HbgA1C was not completed until 08/08/22 and further added the nurses should not have been signing off an order that had not been completed and the order should have fallen off the treatment record once completed. Review of undated policy titled Documentation: Charting revealed the purpose of information in the clinical record is to provide a means of communication between physician, and other professionals contributing to the resident's care, and is a basis for planning and providing care to each resident. Review of undated policy titled Documentation: Charting revealed the purpose of information in the clinical record is to provide a means of communication between physician, and other professionals contributing to the resident's care, and is a basis for planning and providing care to each resident. This deficiency substantiates Complaint Number OH000134514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 15 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, review of staff in-services, review of Centers for Disease Control for Prevention (CDC)guidance, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of COVID-19. This had the potential to affect all 65 residents in the facility. The facility census was 65. Residents Affected - Some Findings include: Observation of the kitchen area on 08/15/22 between 9:00 A.M. and 9:32 A.M. revealed the following: Dietary Aide (DA) #313 was noted scooping topping onto cakes in small round white foam containers. DA #313 was observed without a face mask as required by current recommendations. DA #313 had face mask pulled down under chin. Cook #418 was observed cleaning dishes and cooking at the stove top without face mask as required by current recommendations. [NAME] #418 was observed with face mask below chin. Additional observations on 08/15/22 from 11:35 A.M. to 12:50 P.M. revealed the following: At 11:35 A.M., [NAME] #418 took food temperatures without face mask to cover nose and mouth, as required by current recommendations. The face mask for [NAME] #418 was around the chin. At 11:35 A.M., DA #313 was pulling meal tickets without mask to cover nose and mouth as required by current recommendations. DA #313 had mask around neck. At 11:45 A.M., meal service started with plates prepared for the north hall. [NAME] #418 and DA #313 without face masks to cover nose and mouth as require by current recommendations. Face masks for both the cook and DA were pulled down to cover the chin. At 12:15 P.M., meal service was provided to the dining room. The face masks for [NAME] #418 and DA #313 remained around their chins. Meal service for the dining room was completed at 12:50 P.M. Interview on 08/15/22 at 12:50 P.M., with the Executive Director verified [NAME] #418 and DA #313 did not wear face masks to cover nose and mouth and further verified both had their face masks around their chins throughout meal service. Review of the updated infection control policy titled Personal Protective Equipment, revealed all staff are required to wear a face mask when in the facility. Review of in-service records from 08/01/21 to 08/18/22 revealed all staff persons, including DA #313 and [NAME] #418, revealed all staff were in-serviced on the facilities mask wearing policies and expectations. Review of the Centers for Disease Control for Prevention (CDC), Coronavirus Disease 2019 (COVID-19), Interim Infection Prevention and Control recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated 07/15/20, stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 16 of 17 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 365489 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewood Manor Rehabilitation & Healthcare Center 1330 S Fulton St Port Clinton, OH 43452 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Healthcare Personnel (HCP) should wear a face mask at all times while they are in the healthcare facility, including in break rooms or other spaces where they might encounter co-workers. Review of the undated policy titled Infection Prevention and Control Program revealed the infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Prevention of infection included to educate staff and ensuring that they adhere to proper techniques and procedures. This deficiency substantiates Complaint Number OH00134514. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365489 If continuation sheet Page 17 of 17