Inspection·April 13, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected two residents (#10 and #60) of five residents reviewed for unnecessary medications. The facility census was 73. Residents Affected - Few Findings include: 1. Record review for Resident #60 revealed this resident was admitted to the facility on [DATE] and had diagnoses including type two diabetes mellitus, syncope and collapse, generalized anxiety disorder, and osteoarthritis. Review of the quarterly MDS assessment, dated 10/11/22, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to be independent with setup help only for bed mobility, transfers, toileting, and eating. This resident was assessed to have had a fall since admission, readmission, or the prior assessment. Review of the MDS assessment, dated 12/05/22, revealed this resident was assessed to have had a fall since admission, readmission, or the prior assessment. Review of the quarterly MDS assessment, dated 02/20/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15. This resident was assessed to be independent with setup help only for bed mobility, transfers, toileting, and eating. This resident was assessed to have received antibiotic medication for four out of the seven days of the review period. Further record review for this resident revealed no documentation of antibiotic medication being received by Resident #60 during the MDS review period and revealed no documentation of the resident experiencing a fall between 10/05/22 and 12/05/22. Interview with MDS Nurse #480 on 04/11/23 at 4:17 P.M. verified the 02/20/23 MDS assessment had been coded inaccurately as Resident #60 did not receive an antibiotic medication during the review period. MDS Nurse #480 also verified the 12/05/22 MDS assessment had been coded inaccurately as Resident #60 had not suffered a fall between the 10/11/22 and the 12/05/22 MDS assessments. 2. Record review for Resident #10 revealed this resident was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, dysphagia, obstructive and reflux uropathy, dementia, and peripheral vascular disease. Review of the significant change MDS assessment, dated 09/15/22, revealed this resident had mildly impaired cognition evidenced by a BIMS assessment score of 12. This resident was assessed to require extensive assistance from two staff members for transfers and toileting, to require extensive assistance from one staff member for bed mobility, and to be independent with setup help only for eating. This resident was assessed to have received an anticoagulant medication for seven days during the review period. Review of the quarterly MDS assessment, dated 12/12/22, revealed this resident was assessed to have received an anticoagulant medication for seven days during the review period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 2 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 0641 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment, dated 03/06/23, revealed this resident was assessed to have received an anticoagulant medication for seven days during the review period. Further record review for this resident revealed no documentation of the resident receiving anticoagulant medications from 09/01/22 through 04/11/23. Residents Affected - Few Interview with MDS Nurse #480 on 04/11/23 at 4:17 P.M. verified the 09/15/22, 12/12/22, and 03/06/23 had been coded inaccurately as Resident #10 had not received anticoagulant medication during the review periods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 3 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 observation, record review, interview, and facility policy review, the facility failed to ensure residents were assisted with oral care. This affected one resident (Resident #22) of two residents reviewed for activities of daily living (ADL). The facility census was 73. Residents Affected - Few Findings Include: Review of the medical record for Resident #22 revealed an initial admission date of 06/11/21 with the latest readmission date of 11/03/21 with diagnoses including COVID-19, cerebral infarction (stroke), dementia with behavioral disturbances, dysphagia (difficulty swallowing), cerebrovascular accident (CVA) with left sided hemiplegia (paralysis). Review of the plan of care dated 06/14/21 revealed the resident had a self-care deficit/altered ability to perform activities of daily living (ADL) due to acute illness, decreased mobility related to history of CVA with left sided hemiplegia, impaired cognition with impaired decision making and chooses not to have nails trimmed. Interventions included assist with dressing and grooming as needed, provide all needed assistance with self-care, ADLs and mobility to ensure safe proper completion of task with one to two staff members as needed and staff to anticipate and meet all needs every shift, daily as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had severe cognitive deficit. The resident was dependent on two staff for personal hygiene. On 04/10/23 at 9:52 A M., observation of Resident #22 revealed her lips and tongue were covered with a thick white, stringy film. On 04/11/23 at 8:05 A.M., observation of the resident revealed the resident's lips and tongue remained with a moist, thick white stringy film. On 04/11/23 at 2:35 P.M., observation of the resident's mouth revealed the resident's lips and tongue continues to have a thick white stingy film. On 04/12/23 at 7:58 A.M., observation of the resident revealed her lips continued with the thick white coating. On 04/12/23 at 8:00 A.M., interview with Licensed Practical Nurse (LPN) #760 verified the resident's mouth had a thick white stingy coating to her lips and tongue and was in need of oral care. Review of the facility's policy titled, Oral Care Policy, last revised 12/10 revealed oral care will be available to all residents to assist with the maintenance functional ability, proper dental hygiene and prevent illness and/or infection. Residents will be given oral care including assistance with oral prostheses routinely, in the morning, at bedtime and as needed in between those times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 4 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide residents with a resident centered activity program. This affected one resident (Residents #22) of two residents reviewed for activities. The facility census was 73. Residents Affected - Few Findings Include: Review of the medical record for Resident #22 revealed an initial admission date of 06/11/21 with the latest readmission of 11/03/21 with diagnoses including COVID-19, cerebral infarction (stroke), dementia with behavioral disturbances, dysphagia (difficulty swallowing), adjustment disorder, and cerebrovascular accident (CVA) with left sided hemiplegia. Review of the plan of care dated 12/30/21 revealed the resident was completely dependent on staff for activities and will take part in appropriate one on one activities. Interventions included staff will converse with the resident during care, appropriate one on one activities such as music and memory, aromatherapy and reading. Review of the plan of care dated 08/11/22 revealed the resident was dependent on staff to provide one on one activities due to health issues. Interventions included provide sensory stimulation, treat with respect, the resident enjoyed listening to music and watching the television, going outside when the weather permits, having nails painted, enjoyed when staff read cards and mail, lotion rubs, music and religious readings during one on one visits, talks about current events and the weather, praise efforts and be positive with the resident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had severe cognitive deficit. Review of the medical record revealed the latest activity participation review was completed on 03/21/23. The review indicated the resident was dependent on staff for activities and enjoyed one on one activities. The resident's showed enjoyment with memory and music program, receiving massages, being taken for walks around the community and listening to staff converse. The plan was to continue appropriate one on one activities. Review of the resident's activity participation log from 01/12/23 to 01/31/23 revealed one visit of one on one activities. Review of the resident's activity participation log from 02/01/23 to 02/28/23 revealed the resident was provided four visits one on one activities for the month of February 2023. Review of the resident's activity participation log from 03/01/23 to 03/31/23 revealed the resident was provided eight visits of one on one activities for the month of March 2023. Review of the resident's activity participation log from 04/01/23 to 04/12/23 revealed the resident was provided one visit of one on one activities for the month of April 2023. On 04/10/23 at 9:52 A.M., observation of the resident revealed she was quiet and the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 5 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resting in bed. The roommate's privacy curtain was pulled to the bottom of the resident's bed blocking any view through the window. The resident's privacy curtain was pulled to the bottom of the resident's bed blocking any view into the hallway. The resident's side of the room was dark with no stimulation. On 04/10/23 at 3:50 P.M., observation of the resident revealed the resident remained in bed with the curtains pulled with no stimulation. On 04/11/23 at 8:05 A.M., observation of the resident revealed the resident was quiet and resting in bed with her eyes closed. The curtains remained pulled, the room was dim, with no stimulation. On 04/11/23 at 2:35 P.M., observation of the resident revealed the resident was quiet and resting in bed with her eyes closed. The curtains remained pulled, the room was dim, with no stimulation. On 04/12/23 at 7:58 A.M., observation of the resident revealed the resident was quiet and resting in bed with her eyes closed. The curtains remained pulled, the room was dim, with no stimulation. On 04/12/23 at 10:15 A.M., interview with Activity Director (AD) #190 verified the resident had no individualized activity program. She verified the resident was unable to complete independent activities however the resident was not provided preferred activities per her care plan or activity review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 6 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 observation, medical record review, review of patient leaflet and staff interview, the facility failed to ensure a medication error rate of less than five percent. Twenty-five opportunities for error were observed with two medication errors resulting in an eight percent (8%) medication error rate. This affected two (Resident #25 and Resident #26) of four residents observed during medication administration. The facility census was 73. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #26 revealed an initial admission date of 10/13/21 with the admitting diagnoses including dementia, diabetes mellitus, congestive heart failure, chronic kidney disease and major depressive disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had severe cognitive deficit. Review of the monthly physician orders identified an order dated 12/16/22 for Flonase (inhaled steroid medication) Suspension one spray in both nostrils twice daily for allergies. On 04/11/23 at 8:22 A.M., LPN #760 was observed to prepare and administer Resident #26's medication. LPN #760 administered two sprays of Flobase in each of the resident's nostrils. On 04/11/23 at 8:24 A.M., interview with LPN #760 confirmed two sprays of Flonase Suspension was administered in each of the resident's nostrils and the order was one spray in each nostril, resulting in a medication error. 2. Review of the medical record for Resident #25 revealed an initial admission date of 03/08/22 with the admitting diagnoses including diabetes mellitus, hypothyroidism, hypertension, anemia, restless leg syndrome and osteoporosis. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had clear speech, understood others, made herself understood and had no cognitive deficit. Review of the plan of care revealed the resident had no plan of care addressing the diagnoses of hypothyroidism and use of the medication levothyroxine (thyroid medication). Review of the monthly physician orders for April 2023 identified orders revealed levothyroxine 75 micrograms (mcg) by mouth daily for hypothyroidism. On 04/11/23 at 8:35 A.M., observation of LPN #760 revealed the LPN prepared medications for Resident #25 which included levothyroxine 75 mcg. The resident was drinking milk and a nutritional supplement for her breakfast meal. LPN #760 administered Resident #25 her medications, including levothyroxine. On 04/11/23 at 8:40 A.M., interview with LPN #760 confirmed the levothyroxine was not administered on an empty stomach. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365669 If continuation sheet Page 7 of 8 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 365669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Four Winds Nursing Facility 215 Seth Avenue Jackson, OH 45640 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 Review of the un-dated patient information leaflet for levothyroxine, revealed the medication should be taken 30 to 60 minutes prior to breakfast, on an empty stomach. 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: 365669 If continuation sheet Page 8 of 8