Health inspection·January 28, 2026

F 0697 Provide safe, appropriate pain management 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 closed medical record review, staff interview and review of facility policy, the facility failed to implement pain management interventions timely to address resident pain. This affected one (#78) of three residents reviewed for pain management. The facility census was 77.Findings include:Review of the closed medical record for Resident #78 revealed an admission date of 01/02/26 and a discharge date of 01/14/26. Diagnoses included spinal stenosis, lumbar region with neurogenic claudication, acute cystitis without hematuria, anxiety, and depression.Review of the hospital progress notes dated 12/26/25 revealed Resident #78 was admitted to the hospital for back and leg pain. On 01/03/26, Resident #78 was discharged to the facility with an order for oxycodone five milligrams (mg) by mouth every eight hours, if needed, for pain for up to three days.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Further review of the MDS revealed Resident #78 was on opioid medication.Review of the care plan dated 01/04/25 revealed Resident #78 was at risk for pain due to lumbago (pain and stiffness in the lower back) with sciatica and neuropathy. Interventions included administering analgesics as ordered by the doctor, offering non-pharmacological pain interventions, and notifying the physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain.Review of the physician orders for Resident #78 revealed orders dated 01/02/26 to assess pain and discomfort every shift and oxycodone five mg, give one tablet by mouth every eight hours as needed for pain.Review of the Medication Administration Record (MAR) for January 2026 revealed oxycodone five mg was not administered from 01/02/26 through 01/05/26. Review of Pain Level Summary revealed Resident #78 had a pain level of two and four on 01/02/26, a pain level of three and four on 01/03/26, a pain level of 4 on 01/04/26, and a pain level of three, four, and six on 01/05/26.Interview on 01/21/26 at 9:54 A.M. with the Director of Nursing (DON) confirmed Resident #78 was admitted to the facility with a prescription for oxycodone. The DON stated Resident #78's prescription was not faxed to the pharmacy upon admission, so the medication was not received by the facility. The DON further stated that Resident #78's daughter was often in the building, or on the phone with Resident #78, and would tell the DON that Resident #78 was in pain. The DON stated on 01/05/26, it was discovered that the oxycodone prescription was never sent to the pharmacy and nursing was made aware and instructed to pull from the contingency box (c-box; on hand supply of medications for immediate use). The DON stated on 01/06/26, Resident #78 was in her room crying from pain. The DON asked Licensed Practical Nurse (LPN) #138 if the medication was available and LPN #138 stated that it did not come in the tote (from the pharmacy) and LPN #138 did not call to pull the medication (authorization needed from the pharmacy to remove narcotic medications from the c-box). The DON confirmed oxycodone was available for administration to Resident #78 to help manage her pain, but nursing staff did not access it from the c-box for administration. Additionally, the DON stated Resident #78 requested an ice pack to help ease her pain and nursing staff told the resident there were no ice packs available, adding there were multiple ice packs available at each nurses' station. The DON verified Resident #78 was not provided neither pain medication or non-pharmacological interventions to manager her pain from 01/02/26 through 01/05/26. Review of the facility policy titled, Pain Management, dated 04/28/25, revealed the facility must ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Non-pharmacological interventions would include, but not limited to, physical modalities such as cold compress.This deficiency represents Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365737 If continuation sheet Page 2 of 5 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 365737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614 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 0697 noncompliance investigated under Master Complaint Number 2709655. 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: 365737 If continuation sheet Page 3 of 5 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 365737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on staff interview, review of facility maintenance work order logs, and review of plumbing vendor documents, the facility failed to ensure hot water temperatures were maintained at acceptable levels. This affected 19 (#8, #12, #15, #24, #29, #31, #32, #36, #45, #57, #60, #62, #65, #67, #69, #71, #73, #77, and #78) residents who were identified by the facility as residing on the Middle North and North Back Halls. The facility census was 77.Findings include:Interview on 01/21/26 at 9:52 A.M. with the Administrator revealed on 12/31/25, the hot water was left running in Mechanical Room Five, leaving no hot water on the Middle North and North Back hallways. When it was identified that there was no hot water on those hallways, Maintenance Assistant (MA) #151came to the facility, turned the faucet off in Mechanical Room Five and waited until the water temperature was back to an acceptable range. On 01/04/26, the Director of Nursing (DON) informed him that there was again no hot water. Maintenance Supervisor (MS) #150 checked Mechanical Room Five and smelled gas, so the hot water was shut off while a replacement part was ordered to repair the hot water tank. The Administrator stated the part was ordered on 01/06/26.Interview on 01/21/26 at 9:54 A.M. with the DON revealed she was aware of the hot water being out on 12/31/25. A group message with management was sent out after the Certified Nursing Assistants (CNAs) reported no hot water on the Middle North and North Back hallways. The DON stated MA #151 reported the issue was fixed and the facility had hot water. Then, on 01/04/26, Resident #73's family member informed her the resident's shower could not be completed due to the facility having no hot water. The family member stated staff informed her the hot water had been out over the weekend, including 01/02/26, 01/03/26 and 01/04/26 The DON stated MS #150 was contacted, as well as the Administrator regarding the hot water concern.Interview on 01/28/26 at 1:08 P.M. with MA #151 revealed on 12/31/25 he received a call to go to the facility and check the North hallway because the water was cold. MA #151 stated there was a sink in Maintenance Room Five that had been left on with the hot water running. MA #151 stated the faucet was turned off and the temperature at the hot water tank increased to an acceptable range after 45 minutes. MA #151 further stated the hot water temperatures were checked in two resident rooms and the nourishment room, with each being within acceptable ranges. MS #151 confirmed there was no monitoring of the water temperatures on 01/01/26, 01/02/26, 01/03/26, and 01/04/26 to ensure the water temperatures were maintained.Interview on 01/28/26 at 1:19 P.M. with Licensed Practical Nurse (LPN) #136 confirmed she worked on 01/03/26 and there was no hot water on the Middle North and North Back hallways, and the CNA made Central Supply (CS) #105 aware.Interview on 01/28/26 at 1:38 P.M. with CNA #176 revealed she worked the day shift on 01/03/26 and there was no hot water on the North Back or North Middle hallways. CNA #176 stated it was reported CS #105.Interview on 01/28/26 at 2:09 P.M. with CS #105 revealed she was present in the facility on 01/02/26 and stated staff did not make her aware of the hot water concern. CS #105 stated she was the manager on duty on 01/04/26 and was present at the facility. CS #105 stated she completed morning rounds and none of the staff reported any concerns with the hot water. At 11:27 A.M., CS #105 stated she was contacted by the DON and asked if she was aware there was no hot water because a resident's family reported to her there had been no hot water for three days on the North hallway. CS #105 denied she had knowledge and went to investigate and was told there had been no hot water for three days. CS #105 stated she ensured there were sufficient hygiene supplies available, such as hand sanitizer and wipes, to provide care for residents on the affected hall.Review of the maintenance work order log from 12/25/25 through 01/04/26 revealed no evidence staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365737 If continuation sheet Page 4 of 5 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 365737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heatherdowns Rehab & Residential Care Center 2401 Cass Rd Toledo, OH 43614 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete reported any hot water concerns in the facility.Review of the plumbing vendor documents revealed the hot water tank was replaced on 01/07/25.The deficiency was corrected on 01/12/26 when the facility implemented the following corrective actions:On 12/31/25, LPN #148 notified the DON that there was not any hot water on the North hallway. MS #150 was notified and explained that MA #151 entered the facility and shut off the hot water faucet that had been left running. MA #151 was a the facility from 7:00 P.M. to 9:00 P.M. and verified that the water temperature on the hot water tank was 118 degrees Fahrenheit (F).On 01/04/26, MS #150 notified the plumbing vendor of an issue with the hot water on the North Middle and North Back hallways. The vendor scheduled to come to the facility on [DATE]. On 01/04/26, CS #105 provided verbal education to all staff working on first and second shift to obtain hot water from either the Front North Hall or the South Unit for resident care, and showers could be completed in the South Unit shower room. LPN #134 provided the education to staff working third shift that night. On 01/04/26, CS #105 ensured a sufficient supply of hand sanitizer and incontinence wipes were available to provide care for the residents residing on the North Middle and North Back Halls. On 01/05/26, the plumbing vendor assessed the hot water tanks that supplied hot water to the North Middle and North Back Halls and determined one hot water tank was inoperable and the second tank required a new gas valve, which had to be ordered. On 01/05/26, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the concern with the hot water on the North Middle and North Back Halls. In attendance were the Administrator, the DON, Admissions Director (AD) #153, Business Office Manager (BOM) #104, Social Worker (SW) #212, Human Resources (HR) #213, Director of Rehabilitation (DOR) #207, Medical Records (MR) #155, Unit Manager (UM) #194, Activities Director (ACT) #101, CS #105, and UM #195. The Administrator instructed each department head to check in with their assigned residents under the Guardian Angel program to explain the situation with the hot water and ensure resident needs were met.Beginning on 01/05/26, CS #105 ensured adequate hand sanitizer and incontinence wipes were available for resident care until the hot water could be restored. Beginning on 01/05/26, the DON or designee began education with nursing department staff to explain options available for providing care, including hand sanitizer, incontinence wipes, obtaining hot water from the South Hall, using the showers on the South Hall or the Therapy Department shower, customer service, infection control, and the reporting of maintenance concerns via work orders and if not resolved, report again to the Administrator and DON for follow-up. On 01/05/26, the DON or designee reviewed all residents residing on the North Middle and North Back Halls to determine any residents who missed showers due to not having hot water on the hall. On 01/06/26, CNA #170 completed showers for residents residing on the North Middle and North Back Halls.On 01/06/26, the plumbing vendor replaced the faulty gas valve on one of the hot water tanks.On 01/07/26, the plumbing vendor replaced the inoperable hot water tank.Beginning on 01/12/26, MS #150 and MA #151 would conduct 10 random water temperature audits throughout the facility daily five times weekly for 30 days to ensure water temperatures were maintained. Any identified concerns would be reported to the Administrator and/or DON and the plumbing vendor notified for service.Random observations on 01/21/26 and 01/28/26 verified hot water temperatures were within acceptable ranges.This deficiency represents noncompliance investigated under Master Complaint Number 2709655 and Complaint Number 2709561. Event ID: Facility ID: 365737 If continuation sheet Page 5 of 5