Inspection·August 29, 2018

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic pain, heart failure, coronary artery disease, and obesity. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. Review of section, investigate, revealed once the Administrator and ODH are notified, an investigation of the allegation violation will be conducted. The investigation must be completed within five working days unless there are special circumstances. If a staff member is accused or suspected of abuse or neglect the facility should immediately remove that staff member from the facility and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 2 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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 schedule pending the outcome of the investigation. 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: 365768 If continuation sheet Page 3 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to report allegations of abuse to the state agency. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91. Findings include: 1. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses that included irritable bowel syndrome, dizziness and giddiness, anemia, adult failure to thrive, heart failure, and major depressive disorder. The resident was hospitalized from [DATE] through 08/19/18 for a right hip sustained after a fall in the facility. Review of the minimum data set (MDS) assessment, dated 07/07/18, revealed a brief interview for mental status (BIMS) of 14. Interview on 08/26/18 at 2:41 P.M. with Resident #69 revealed State Tested Nurse Aide (STNA) #64 was loud and rough when providing care. The resident stated she fought with me, she yelled and screamed at me, I wasn't sitting right, I wasn't walking right, I wasn't doing anything right, it was horrible. Further interview revealed allegations that STNA #64 drug her (with assist of an unnamed STNA) to the bathroom in the middle of the night. The resident reported being a nervous wreck ever since STNA #64 worked with her. Interview on 08/28/18 at 11:51 A.M. with Registered Nurse (RN) Unit Manager #29 revealed she was aware that STNA #64 had upset Resident #69 by saying you need to try, you are weight bearing as tolerated. Further interview revealed RN #29 had not interviewed the resident and/or other residents on the unit regarding care provided by STNA #64. Interview on 08/28/18 at 12:15 P.M. with STNA #39 revealed Resident #69 had complained about care provided by STNA #64. She stated STNA #64 was too rough with putting her to bed and assisting her to the bathroom. Interview on 08/28/18 at 12:24 P.M. with Licensed Practical Nurse (LPN) #85 revealed Resident #69 reported allegations that STNA #64 was rough and told her she should be doing more for herself. Further interview revealed she reported the allegations to LPN #59 on 08/25/18 at 7:00 P.M. during shift change. Interview on 08/28/18 at 12:08 P.M. with the Director of Nursing (DON) revealed she was notified on 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 4 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic pain, heart failure, coronary artery disease, and obesity. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 5 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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, resident and staff interview, review of facility self-reported incidents (SRI's) and review of facility policy, the facility failed to thoroughly investigate allegations of abuse. This affected two (#69 and #73) of two residents reviewed for abuse. The census was 91. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses that included irritable bowel syndrome, dizziness and giddiness, anemia, adult failure to thrive, heart failure, and major depressive disorder. The resident was hospitalized from [DATE] through 08/19/18 for a right hip sustained after a fall in the facility. Review of the minimum data set (MDS) assessment, dated 07/07/18, revealed a brief interview for mental status (BIMS) of 14. Interview on 08/26/18 at 2:41 P.M. with Resident #69 revealed State Tested Nurse Aide (STNA) #64 was loud and rough when providing care. The resident stated she fought with me, she yelled and screamed at me, I wasn't sitting right, I wasn't walking right, I wasn't doing anything right, it was horrible. Further interview revealed allegations that STNA #64 drug her (with assist of an unnamed STNA) to the bathroom in the middle of the night. The resident reported being a nervous wreck ever since STNA #64 worked with her. Interview on 08/28/18 at 11:51 A.M. with Registered Nurse (RN) Unit Manager #29 revealed she was aware that STNA #64 had upset Resident #69 by saying you need to try, you are weight bearing as tolerated. Further interview revealed RN #29 had not interviewed the resident and/or other residents on the unit regarding care provided by STNA #64. Interview on 08/28/18 at 12:15 P.M. with STNA #39 revealed Resident #69 had complained about care provided by STNA #64. She stated STNA #64 was too rough with putting her to bed and assisting her to the bathroom. Interview on 08/28/18 at 12:24 P.M. with Licensed Practical Nurse (LPN) #85 revealed Resident #69 reported allegations that STNA #64 was rough and told her she should be doing more for herself. Further interview revealed she reported the allegations to LPN #59 on 08/25/18 at 7:00 P.M. during shift change. Interview on 08/28/18 at 12:08 P.M. with the Director of Nursing (DON) revealed she was notified on 08/25/18 at 7:42 P.M. by LPN #59 via text messages of the allegations. The text message read there was a complaint from the resident on STNA #64. LPN #59 assumed all direct care for Resident #69 the remainder of the shift. STNA #64 continued to work the shift taking care of other residents. Further interview confirmed Resident #69 and/or other residents had not been interviewed regarding allegations of abuse. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #69. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 6 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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 2. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic pain, heart failure, coronary artery disease, and obesity. Review of the MDS assessment, dated 08/01/18, revealed a BIMS of 15. Further review revealed the resident required extensive staff assist with transfers and toileting. Interview on 08/28/18 at 12:34 P.M. with Activities Assistant #13 revealed Resident #73 complained about care provided by STNA #64 on 06/25/18. Resident #73 had asked for assistance with going to the bathroom. The resident reported that STNA #64 told her to go in her diaper. Further interview revealed Activities Assistant #13 gave a written statement regarding the allegation to the Assistant Director of Nursing (ADON). Interview on 08/28/18 at 12:44 P.M. with the Assistant DON (ADON) revealed she was aware Resident #73 reported an allegation that STNA #64 would not let her use the bed pan. Further interview revealed no further investigation was done by the ADON. Interview on 08/28/18 at 4:05 P.M. with Resident #73 revealed an STNA told her to pee in her diaper because they were not putting her on the bedpan. Interview on 08/28/18 at 5:00 P.M. with the Administrator confirmed an investigation had not been initiated regarding the allegation of abuse from Resident #73. Further interview confirmed the facility did not report an allegation of abuse to the required officials per policy. Review of the facilities SRI's revealed no incident/investigations regarding Resident #69 or #73's allegations. Review of the undated facility policy titled Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of section, initial report, revealed the Administrator or designee will notify the Ohio Department of Health (ODH) of all alleged violations involving mistreatment, neglect, and abuse as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to ODH immediately, but not later than two hours after the allegation is made. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 7 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notice of discharge and transfer to residents, resident's representative, and the ombudsman. This affected two (#23 and #82) of two residents reviewed for hospitalizations. The census was 91. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, acute kidney failure, type II diabetes mellitus, and functional quadriplegia. Further review revealed Resident #23 was transferred to the hospital on [DATE]. A written notice of the transfer was not given to the resident, resident's representative, or the ombudsman. The resident returned to the facility on [DATE]. Interview on 08/28/18 at 6:00 P.M. with the Administrator confirmed written notice of Resident #23's transfer was not given to the resident, resident's representative, or the ombudsman. 2. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses that included hypertension, Crohn's disease, anxiety, and aftercare following surgery on the digestive system. Further review revealed Resident #82 was transferred to the hospital on [DATE]. A written notice of the transfer was not given to the resident, resident's representative, or the ombudsman. The resident did not return to the facility. Interview on 08/28/18 at 6:00 P.M. with the Administrator confirmed written notice of Resident #82's transfer was not given to the resident, resident's representative, or the ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 8 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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 and staff interview, the facility failed to provide written notice of the bed hold policy to residents and resident's representative when transferred to the hospital. This affected two (#23 and #82) of two residents reviewed for hospitalizations. The census was 91. Findings include: 1. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, acute kidney failure, type II diabetes mellitus, and functional quadriplegia. Further review revealed Resident #23 was transferred to the hospital on [DATE]. A written notice of the bed hold policy was not given to the resident or the resident's representative. The resident returned to the facility on [DATE]. Interview on 08/28/18 at 6:00 P.M. with the Administrator confirmed Resident #23 and/or Resident #23's representative was not given written notice of the bed hold policy. 2. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses that included hypertension, Crohn's disease, anxiety, and aftercare following surgery on the digestive system. Further review revealed Resident #82 was transferred to the hospital on [DATE]. A written notice of the bed hold policy was not given to the resident or the resident's representative. The resident did not return to the facility. Interview on 08/28/18 at 6:00 P.M. with the Administrator confirmed Resident #82 and/or Resident #82's representative was not given written notice of the bed hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 9 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of standing house orders, the facility failed to monitor Resident #23's bowel status and implement their standing house orders as directed. This resulted in Actual Harm when Resident #23 did not have a bowel movement for six days and the resident was subsequently hospitalized for an acute large bowel obstruction. This affected one (#23) of two residents reviewed for hospitalization. Facility census was 91. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, coronary artery disease, hypertension, type II diabetes mellitus, vascular dementia, functional quadriplegia, and dysphagia. Review of the admission minimum data set (MDS) assessment, dated 06/29/18, revealed the residents brief interview for mental status was not assessed due to being rarely or never understood. Further review revealed the resident was frequently incontinent of bowel and required extensive staff assist with toileting. Review of the care plan, initiated 07/05/18, revealed Resident #23 was prone to constipation, had decreased mobility, and a history of constipation. The goal was for Resident #23 to have a bowel movement every one to three days. Care plan interventions instructed staff to monitor for a bowel movement every shift. Review of physician orders from dates 06/22/18 through 08/01/18 revealed routine stool softeners were not ordered for Resident #23. Further review of orders, dated 06/22/18, revealed Resident #23 was to receive Tramadol (pain medicine that can cause constipation) 50 milligrams (mg) three times daily. Review of a report titled Look Back Report regarding Resident #23's bowel movement history revealed the resident had a medium bowel movement documented on 07/26/18 at 4:16 A.M. Further review of the report revealed the resident did not have a bowel movement documented on 07/27/18, 07/28/18, 07/29/18, 07/30/18 or 07/31/18. Review of progress notes dated 08/01/18 at 6:20 A.M. (late entry) revealed Resident #23 had large emesis (vomiting). The resident's abdomen was slightly distended, was passing gas, and had three small bowel movements while turning and repositioning. Review of progress notes, dated 08/01/18 at 2:30 P.M., revealed Resident #23 had nausea with periodic emesis since the morning. The resident had a large bowel movement, however the nausea and vomiting continued. The resident's abdomen was distended and firm. After suppositories (for constipation) were given and an abdominal x-ray was obtained the resident was sent to the emergency room for evaluation at 11:30 P.M. Review of the hospital history and physical, dated 08/02/18, revealed Resident #23 was admitted with an acute large bowel obstruction, gastrointestinal hemorrhage, and acute kidney failure. The resident had nausea, vomiting, and abdominal distention likely due to large bowel obstructions from fecal impaction. The plan was to aggressively treat constipation with stool softeners and a daily enema. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 10 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The resident was hospitalized for six days and returned to the facility on [DATE]. Level of Harm - Actual harm Interview on 08/27/18 at 4:02 P.M. with the Director of Nursing (DON) confirmed Resident #23 had no bowel movement times for a period of six days (07/26/18 to 08/01/18). Further interview confirmed the facility did not assess the resident after not having a bowel movement after three days and did not follow standing house orders for constipation. The DON confirmed Resident #23 was admitted to the hospital for an acute large bowel obstruction. Residents Affected - Few Review of standing house orders, physician approved 07/03/18, revealed if the resident does not have a bowel movement for three days to assess their bowel sounds and document in nurses' notes, administer 120 milliliters (ml) of prune juice with breakfast, and assess manually for stool after each meal removing if present. If prune juice is ineffective and no stool present upon manual assessment, administer milk of magnesia (for constipation) 30 milliliter (ml) by mouth before the end of first shift. Further review revealed if the resident does not have a bowel movement for four days the facility is to assess bowel sounds and document in nurse's notes and assess manually for stool after each meal. If no stool present, administer Bisacodyl (for constipation) 10 milligram (mg) suppository rectally times one by 6:00 A.M. unless contraindicated. If no results from Bisacodyl within eight hours, administer Fleets enema times one at 2:00 P.M. If no results from Fleets enema within one hour, administer soapsuds enema. If no results from soap suds enema contact physician immediately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 11 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, review of dietary spreadsheets, and staff interview the facility failed to serve bread per the dietician approved spreadsheet to residents receiving puree diets. This affected eight (#6, #8, #17, #43, #49, #61, #64, and #66) of eight residents receiving pureed diets. The census was 91. Findings include: Observation during lunch on 08/27/18 at 11:25 A.M. revealed bread was not served to residents receiving pureed diets. Review of the dietician approved spreadsheet revealed residents receiving pureed diets were to receive a pureed wheat roll for lunch on 08/27/18. Interview on 08/27/18 at 11:35 A.M. with Dietary Manager #109 confirmed bread was not served to residents receiving pureed diets. Further interview revealed the facility stopped serving pureed bread items approximately one year ago due to residents dislike. Interview on 08/28/18 at 11:39 A.M. with Registered Dietician #144 revealed she was aware residents were not receiving pureed bread, but was not aware it was still on the spreadsheet. The facility confirmed eight (#6, #8, #17, #43, #49, #61, #64, and #66) residents receive pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 12 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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, staff interview, review of a dietary listing and review of policy, the facility failed to ensure pans were appropriately dried to maintain proper sanitation. In addition, the facility failed to store ready to use icing in the refrigerator per label to prevent contamination. This had to the potential to affect all residents residing in the facility. The census was 91. Findings include: 1. Observation on 08/26/18 at 9:00 A.M. during the initial tour of the kitchen revealed seven stacks of various sized metal storage pans on the shelf. Further observation of Dietary Aide #34 remove pans from each stack revealed condensation on the inside. Two stacks had visible water dripping off the edges. Interview on 08/26/18 at 9:00 A.M. with Dietary Aide #34 confirmed seven stacks of various sized metal storage pans were not dried prior to stacking on the shelves. Further interview revealed the pans were washed and put away the night before. Review of the undated facility policy titled Cleaning Procedure - Pots and Pans revealed to remove the pans from the sanitizing sink and invert on drain board. Let air dry. Do not wipe. 2. Observation on 08/26/18 at 9:00 A.M. during the initial tour of the kitchen revealed one opened container of ready to serve cream cheese icing in the dry storage room. The icing was opened on 08/15/18. Further review of the label read once icing container has been opened, the icing can be stored covered at room temperature for one week. After this time period, store covered in the cooler. Interview on 08/26/18 at 9:00 A.M. with Dietary Aide #34 confirmed the icing was opened on 08/15/18 and had not been stored properly in the cooler. Review of the dietary list revealed all 91 residents receive food from the kitchen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 13 of 14 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 365768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Logan Acres 2739 County Road 91 Bellefontaine, OH 43311 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, list provided by the facility and review of policy and procedures, the facility failed to appropriately clean a glucometer after checking a resident's blood sugar. This affected one (#283) out of one resident observed having their blood sugar checked during medication administration and had the potential to affect five (#2, #16,#32, #41 and #282) additional residents identified by the facility as using the same glucometer for blood sugar monitoring. Facility census was 91. Residents Affected - Some Findings include: Review of list provided by the facility identified six (#2, #16, #32, #41, #282 and #283) Residents as using the same glucometer for blood sugar monitoring. On 08/26/18 at 11:36 A.M. an observation was made of Resident #283 blood sugar check with a glucometer device. At this time Registered Nurse (RN) #100 nurse checked the Resident's blood sugar. When she was completed with the blood sugar check she cleaned the glucometer device with an alcohol prep pad and placed it back in the medication cart drawer. On 08/26/18 at 11:38 A.M. an interview with RN #100 verified she cleaned the glucometer with an alcohol prep pad. She stated she isn't sure but she did have the proper sanitizing wipes available in her cart. She revealed she is not sure if the facility is out so it had to be cleaned with something. She verified there are six (#2, #16, #32, #41, #282 and #283) residents all together who use the same glucometer machine for the unit. Review of policy titled glucometer-infection control/disinfecting dated 11/29/17 documented the glucometer must be cleaned with super sani-cloth germicidal disposable wipes after each resident use. The glucometer is to be wiped down. The glucometer is to be wet for two full minutes and be left out to air dry for each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365768 If continuation sheet Page 14 of 14