Inspection·February 21, 2019

F 0600 the facility. HRM #190 verified she reported the incident to the Administrator by email. Level of Harm - Minimal harm or potential for actual harm Review of the email from HRM #190 to the Administrator, dated Wednesday, 01/16/19 at 4:49 P.M., revealed HRM #190 wanted to commend BOM #107 for handling the incident which occurred involving Resident #23, her daughter and granddaughter. The email indicated Resident #23's daughter was leering and aggressive, pulling her weeping mother out of the office, with BOM #107 attached to her hands. It was loud and threatening. People came to the hall to see if everything was ok. HRM #190 wrote she stood in support of BOM #107, only to have the daughter [NAME] at her. HRM #190 wrote she can't believe it is good for the resident to go through such anguish. Residents Affected - Few Interview on 02/20/19 at 10:33 A.M., the Director of Nursing (DON) verified the instance of physical and verbal abuse toward Resident #23 by her daughter and of the misappropriation of Resident #23's food. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy, dated 2016, revealed the facility will not tolerate abuse, neglect, exploitation and misappropriation of resident property. This citation substantiates the Complaint Number OH00102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 2 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of electronic mail (email) communications, and facility policy review, the facility failed to follow their policy to prevent abuse from occurring, to report allegations of abuse to the state survey agency, and to investigate allegations of abuse for one (#23) of six residents reviewed for abuse. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed she was admitted to the facility on [DATE]. Diagnoses included saddle embolus of the pulmonary artery, congestive heart failure, chronic obstructive pulmonary disease, maxillary sinusitis, diverticulosis of the large intestine, hypertension and chronic fatigue. Interview on 02/20/19 at 9:31 A.M., Office Manager (BOM) #107 revealed on 01/16/19 Resident #23 came to the business office. She was in her wheelchair and accompanied by her daughter and granddaughter. Resident #23 informed BOM #107 she wanted $50.00 because her daughter and granddaughter needed it to get food. BOM #107 stated the daughter immediately became verbally aggressive, yelling and cussing. The daughter yelled at Resident #23 for saying she wanted the money for her, said she had told her she did not want the money, and saying the resident should not have told BOM #107 the money was for the daughter. The daughter was yelling the money was for Resident #23 and not for her. The daughter was physically aggressive, shaking her finger at both Resident #23 and BOM #107, approaching them in a threatening manner. BOM #107 stated Resident #23 began to cry and appeared to fearful. BOM #107 stated she also felt fearful because of the daughter's aggressive, loud and threatening behavior. BOM #107 stated the resident was holding her hands. She verified she attempted to defuse the angry outburst with calm communication. The daughter continued with the verbal aggression, grabbed Resident #23's wheelchair and forcefully removed Resident #23 from the office. BOM #107 stated Resident #23 was still holding her hands and did not let go of her hands. The daughter pulled on Resident #23's wheelchair so forcefully she dragged both Resident #23 and the BOM out into the hall because Resident #23 held tightly to her hands and did not let go of her. The daughter and granddaughter eventually left the facility without the money. BOM #107 stated Resident #23 later reported her daughter and granddaughter had gone to her room and took her Cheez-its and an apple from her room prior to leaving the facility. BOM stated she reported the incident to the Administrator. Interview with Regional Human Resource Manager (HRM) #190 on 02/20/19 at 10:01 AM. verified she was present in the business office on 01/16/19 at the time of the incident with Resident #23 and her daughter. HRM #190 confirmed the statements by BOM #107. HRM #190 verified the daughter was very threatening, shaking her finger in Resident #23's and BOM #107's face, yelling, cussing and blaming Resident #23 for her and the granddaughter having no food and no money, since the resident admitted to the facility. HRM #190 verified she reported the incident to the Administrator by email. Review of the email from HRM #190 to the Administrator, dated Wednesday, 01/16/19 at 4:49 P.M., revealed HRM #190 wanted to commend BOM #107 for handling the incident which occurred involving Resident #23, her daughter and granddaughter. The email indicated Resident #23's daughter was leering and aggressive, pulling her weeping mother out of the office, with BOM #107 attached to her hands. It was loud and threatening. People came to the hall to see if everything was ok. HRM #190 wrote she stood in support of BOM #107, only to have the daughter [NAME] at her. HRM #190 wrote she can't believe it is good for the resident to go through such anguish. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 3 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/20/19 at 10:33 A.M., the Director of Nursing (DON) verified the facility did not complete an investigation in regard to the alleged physical and verbal abuse toward Resident #23 by her daughter and of the misappropriation of Resident #23's food. The DON verified the facility did not submit a Self-Reported Incident report (SRI) to the state of Ohio. Interview with Corporate Regional Manager (CRM) #189 on 02/20/19 at 11:46 A.M. verified the Administrator was aware of the alleged physical and verbal abuse and misappropriation of Resident #23's food. CRM #189 verified there was no SRI or investigation completed. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy, dated 2016, revealed the facility will not tolerate abuse, neglect, exploitation and misappropriation of resident property. It is the facility policy to investigate all alleged violations, involving abuse, neglect, exploitation, and misappropriation of resident property in accordance with this policy. The facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. The Administrator or a designee will notify ODH of all alleged violations involving abuse, neglect, exploitation and misappropriation of resident property as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This citation substantiates the Complaint Number OH00102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 4 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of electronic mail (email) communications, and facility policy review, the facility failed to report allegations of abuse to the state survey agency for one (#23) of six residents reviewed for abuse. The facility census was 48. Findings include: Review of the medical record for Resident #23 revealed she was admitted to the facility on [DATE]. Diagnoses included saddle embolus of the pulmonary artery, congestive heart failure, chronic obstructive pulmonary disease, maxillary sinusitis, diverticulosis of the large intestine, hypertension and chronic fatigue. Interview on 02/20/19 at 9:31 A.M., Office Manager (BOM) #107 revealed on 01/16/19 Resident #23 came to the business office. She was in her wheelchair and accompanied by her daughter and granddaughter. Resident #23 informed BOM #107 she wanted $50.00 because her daughter and granddaughter needed it to get food. BOM #107 stated the daughter immediately became verbally aggressive, yelling and cussing. The daughter yelled at Resident #23 for saying she wanted the money for her, said she had told her she did not want the money, and saying the resident should not have told BOM #107 the money was for the daughter. The daughter was yelling the money was for Resident #23 and not for her. The daughter was physically aggressive, shaking her finger at both Resident #23 and BOM #107, approaching them in a threatening manner. BOM #107 stated Resident #23 began to cry and appeared to fearful. BOM #107 stated she also felt fearful because of the daughter's aggressive, loud and threatening behavior. BOM #107 stated the resident was holding her hands. She verified she attempted to defuse the angry outburst with calm communication. The daughter continued with the verbal aggression, grabbed Resident #23's wheelchair and forcefully removed Resident #23 from the office. BOM #107 stated Resident #23 was still holding her hands and did not let go of her hands. The daughter pulled on Resident #23's wheelchair so forcefully she dragged both Resident #23 and the BOM out into the hall because Resident #23 held tightly to her hands and did not let go of her. The daughter and granddaughter eventually left the facility without the money. BOM #107 stated Resident #23 later reported her daughter and granddaughter had gone to her room and took her Cheez-its and an apple from her room prior to leaving the facility. BOM stated she reported the incident to the Administrator. Interview with Regional Human Resource Manager (HRM) #190 on 02/20/19 at 10:01 AM. verified she was present in the business office on 01/16/19 at the time of the incident with Resident #23 and her daughter. HRM #190 confirmed the statements by BOM #107. HRM #190 verified the daughter was very threatening, shaking her finger in Resident #23's and BOM #107's face, yelling, cussing and blaming Resident #23 for her and the granddaughter having no food and no money, since the resident admitted to the facility. HRM #190 verified she reported the incident to the Administrator by email. Review of the email from HRM #190 to the Administrator, dated Wednesday, 01/16/19 at 4:49 P.M., revealed HRM #190 wanted to commend BOM #107 for handling the incident which occurred involving Resident #23, her daughter and granddaughter. The email indicated Resident #23's daughter was leering and aggressive, pulling her weeping mother out of the office, with BOM #107 attached to her hands. It was loud and threatening. People came to the hall to see if everything was ok. HRM #190 wrote she stood in support of BOM #107, only to have the daughter [NAME] at her. HRM #190 wrote she can't believe it is good for the resident to go through such anguish. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 5 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/20/19 at 10:33 A.M., the Director of Nursing (DON) verified the facility did not submit a Self-Reported Incident report (SRI) to the state of Ohio. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy, dated 2016, revealed the facility will not tolerate abuse, neglect, exploitation and misappropriation of resident property. The facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. The Administrator or a designee will notify ODH of all alleged violations involving abuse, neglect, exploitation and misappropriation of resident property as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This citation substantiates the Complaint Number OH00102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 6 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of electronic mail (email) communications, and facility policy review, the facility failed to follow their policy to prevent abuse from occurring for one (#23) of six residents reviewed for abuse. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed she was admitted to the facility on [DATE]. Diagnoses included saddle embolus of the pulmonary artery, congestive heart failure, chronic obstructive pulmonary disease, maxillary sinusitis, diverticulosis of the large intestine, hypertension and chronic fatigue. Interview on 02/20/19 at 9:31 A.M., Office Manager (BOM) #107 revealed on 01/16/19 Resident #23 came to the business office. She was in her wheelchair and accompanied by her daughter and granddaughter. Resident #23 informed BOM #107 she wanted $50.00 because her daughter and granddaughter needed it to get food. BOM #107 stated the daughter immediately became verbally aggressive, yelling and cussing. The daughter yelled at Resident #23 for saying she wanted the money for her, said she had told her she did not want the money, and saying the resident should not have told BOM #107 the money was for the daughter. The daughter was yelling the money was for Resident #23 and not for her. The daughter was physically aggressive, shaking her finger at both Resident #23 and BOM #107, approaching them in a threatening manner. BOM #107 stated Resident #23 began to cry and appeared to fearful. BOM #107 stated she also felt fearful because of the daughter's aggressive, loud and threatening behavior. BOM #107 stated the resident was holding her hands. She verified she attempted to defuse the angry outburst with calm communication. The daughter continued with the verbal aggression, grabbed Resident #23's wheelchair and forcefully removed Resident #23 from the office. BOM #107 stated Resident #23 was still holding her hands and did not let go of her hands. The daughter pulled on Resident #23's wheelchair so forcefully she dragged both Resident #23 and the BOM out into the hall because Resident #23 held tightly to her hands and did not let go of her. The daughter and granddaughter eventually left the facility without the money. BOM #107 stated Resident #23 later reported her daughter and granddaughter had gone to her room and took her Cheez-its and an apple from her room prior to leaving the facility. BOM stated she reported the incident to the Administrator. Interview with Regional Human Resource Manager (HRM) #190 on 02/20/19 at 10:01 AM. verified she was present in the business office on 01/16/19 at the time of the incident with Resident #23 and her daughter. HRM #190 confirmed the statements by BOM #107. HRM #190 verified the daughter was very threatening, shaking her finger in Resident #23's and BOM #107's face, yelling, cussing and blaming Resident #23 for her and the granddaughter having no food and no money, since the resident admitted to the facility. HRM #190 verified she reported the incident to the Administrator by email. Review of the email from HRM #190 to the Administrator, dated Wednesday, 01/16/19 at 4:49 P.M., revealed HRM #190 wanted to commend BOM #107 for handling the incident which occurred involving Resident #23, her daughter and granddaughter. The email indicated Resident #23's daughter was leering and aggressive, pulling her weeping mother out of the office, with BOM #107 attached to her hands. It was loud and threatening. People came to the hall to see if everything was ok. HRM #190 wrote she stood in support of BOM #107, only to have the daughter [NAME] at her. HRM #190 wrote she can't believe it is good for the resident to go through such anguish. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 7 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/20/19 at 10:33 A.M., the Director of Nursing (DON) verified the facility did not complete an investigation in regard to the alleged physical and verbal abuse toward Resident #23 by her daughter and of the misappropriation of Resident #23's food. Interview with Corporate Regional Manager (CRM) #189 on 02/20/19 at 11:46 A.M. verified the Administrator was aware of the alleged physical and verbal abuse and misappropriation of Resident #23's food. CRM #189 verified there was no SRI or investigation completed. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy, dated 2016, revealed the facility will not tolerate abuse, neglect, exploitation and misappropriation of resident property. It is the facility policy to investigate all alleged violations, involving abuse, neglect, exploitation, and misappropriation of resident property in accordance with this policy. This citation substantiates the Complaint Number OH00102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 8 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 medical record review, staff interview, and review of Bed Hold form, the facility failed to develop a policy regarding bed holds upon transfer/discharge and failed to provide notice of bed hold upon transfer/discharge for one (Resident #34) of two residents reviewed for hospitalization. The facility census was 48. Findings include: Review of the medical record for Resident #34 revealed an admission date of 9/25/18. Diagnoses included acute and chronic respiratory failure, heart failure, dysphagia, non-rheumatic aortic stenosis with insufficiency, muscle weakness, acute kidney failure with tubular necrosis, hyperlipidemia, hypertension, anemia, metabolic encephalopathy, pressure ulcer of sacral region stage four, generalized anxiety disorder, hypotension, cognitive communication deficit, major depressive disorder, recurrent, and obstructive sleep apnea. Resident #34 was transferred/discharged on 12/10/18 to the hospital. There was no evidence any bed hold notice was provided to the resident upon transfer/discharge. Interview on 02/20/19 at 2:57 P.M., Resident Services Coordinator (RSC) #165 verified the facility did not provide bed hold notice to Resident #34 before transfer/discharge on [DATE]. RSC #165 stated the facility does not have a bed hold policy, they have a form they give the resident to fill out when they are admitted if they want to bed hold. Review of the Bed Hold form, dated 03/2017, revealed the resident is to choose if their bed is to be held or not held upon transfer/discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 9 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 observation, record review, staff interview, physician interview, and review of the facility policy, the facility failed to accurately assess and document the stage of a pressure ulcer for one (#46) out of three residents review for pressure ulcers. The current census was 48. Residents Affected - Few Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses for Resident #46 included acute and chronic respiratory failure, chronic obstructive pulmonary disease, neuropathy, obesity, pressure ulcer of left buttock unspecified stage, sleep apnea, and anxiety. Review of the physician documentation date 12/26/18 revealed Resident #46's left buttock wound measured 3.6 centimeters (cm) by 2.4 cm with 0.4 cm depth and 2.6 cm area of tunneling. The physician documented the wound as a surrounding deep tissue injury which was purple/maroon. The physician documented the wound as having 50% necrotic tissue with 20% slough. Review of Resident #46's nurse's wound assessment, dated 12/27/18, revealed the wound nurse documented a pressure ulcer on the left buttock measuring 3.6 cm, by 2.4 cm, by 0.4 cm depth and staged as a suspected deep tissue injury. The wound appeared purple/maroon peri-wound with 50% necrotic tissue and 20% slough present. Review of the physician documentation dated 01/30/19 revealed the physician measured the left buttock wound as 4.8 cm by 3.0 cm with 0 cm depth, with 1.2 cm tunneling. No staging or identification of type of wound was noted in the documentation. Review of the resident's nurse wound assessment, dated 01/30/19, described the left buttock wound as measuring 5.5 cm by 3.0 cm by 0 cm depth with no staging documented. Review of Resident #46's care plan dated 01/28/19, revealed a focus for skin breakdown risk and shearing wound. Interventions for the focus included skin assessment and treatments as ordered. Review of the quarterly Minimum Data Set, (MDS) assessment, dated 01/31/19, identified Resident #46 to have intact cognition. Per the MDS assessment the resident was coded has having no unhealed pressure ulcers and no suspected deep tissue injuries. Interview on 02/19/19 at 3:45 P.M., Corporate Registered Nurse (CRN) #188 revealed the physician had not identified Resident #46's buttock wound as a pressure ulcer. CRN #188 indicated the physician stated it was a shearing wound. CRN #188 stated the facility's wound registered nurse was able to stage a pressure ulcer per the nurse's scope of practice. Observation on 02/20/19 at 1:00 P.M. of the dressing change to Resident #46's pressure ulcer by Physician #191 and Case Manager/Wound Nurse (CM) #169 revealed the physician removed the dressing to show a stage three pressure ulcer on the resident's left buttock. The dressing removed from the wound was noted to have scant amount of yellow drainage. The wound bed appeared pink with slough noted around the edges. The physician was observed measuring the wound to the 4.6 cm wide by 3.0 cm length by 0.2 cm deep. The wound appeared to have depth and there was tunnelling at the 7 O ' clock area of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 10 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 the wound. Level of Harm - Minimal harm or potential for actual harm Interview at the time of the observation on 02/20/19 at 1:00 P.M., Physician #191 declined to comment on the stage of the pressure ulcer, only stating it was open with thickness. Residents Affected - Few Interview on 02/20/19 at 4:15 P.M., CM #169 verified the wound had not been staged as a stage three pressure ulcer until 02/20/19. CM #169 verified she was the nurse who originally documented the wound was a suspected deep tissue injury on 12/27/18. Per CM #169 she notified the physician who recommended not staging the pressure ulcer. The wound nurse stated she agreed the wound advanced to a stage three once it opened and met the requirements of a stage three pressure ulcer. Review of the facility policy titled Pressure Ulcer Policy, dated 04/2016, revealed the facility defined a stage three pressure ulcer as a full thickness skin loss involving damage to the subcutaneous tissue that may involve necrosis. Per the policy all residents will be monitored for pressure ulcers and if a pressure ulcer is present will be documented on weekly including the location and staging of the wound. This citation substantiated Complaint Number OH000102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 11 of 12 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 365744 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/21/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Roselawn Manor 420 East Fourth Street Spencerville, OH 45887 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on medical record record review, observation, staff interview, and facility policy review, the facility failed to perform hand hygiene when completing a dressing change. This affected one resident (#34) of two observed for dressing changes. The facility census was 48. Findings include: Review of the medical record for Resident #34 revealed an admission date of 09/25/18. Diagnoses included acute and chronic respiratory failure, acute kidney failure with tubular necrosis, and pressure ulcer of sacral region stage four. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely/never understood and had one stage four pressure ulcer which was present upon admission. Review of the current physician orders revealed Resident #34 had orders dated 02/19/19 to cleanse the coccyx wound with normal saline, then pack the wound with silver alginate, skin prep perimeter of wound, cover wound with folded gauze, secure with Medipore tape daily. Observation on 02/20/19 at 10:30 A.M., revealed Physician #191 completed a dressing change for Resident #34. The physician washed his hands, put on gloves, closed the door and removed the old dressing, using the top of the dressing to pull out the wound packing. The old dressing contained serous sanquinous drainage. The physician did not wash his hands or change gloves. He then measured the wound, applied a skin prep around the perimeter of the wound, placed alginate into the wound with tweezers, covered the wound with folded gauze and covered with sterile gauze. Interview on 2/20/19 at 10:35 A.M., Physician #191, verified he did not remove his dirty gloves after removing the old dressing or wash his hands and put new gloves on before cleansing the wound and applying the new dressing. Interview on 2/20/19 at 10:36 A.M., with Case Manager #169 verified they would normally remove gloves and wash hands after removing a dirty dressing. Review of the policy titled Standard Precautions, undated, revealed hands must be thoroughly washed immediately after contact with blood, body fluids or tissues. This deficiency substantiates Complaint Number OH00102458. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365744 If continuation sheet Page 12 of 12