Health inspection·July 18, 2019

F 0685 Level of Harm - Minimal harm or potential for actual harm An interview on 07/16/19 at 3:17 P.M. with LPN #100 revealed Resident #25's daughter told her it was probably time to get the hearing aides checked. LPN #100 confirmed there was no evidence in the chart of any hearing aid checks after the 12/10/18 audiology visit. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and facility policy, the facility failed to ensure medications were taken at the time of administration. This affected one Resident (#9) of 27 residents observed during the screening process. The facility identified 11 residents who were cognitively impaired and independently mobile. The facility census was 27. Findings include: Review of Resident #9's medical record revealed an admission date of 07/18/19. Diagnoses included malignant neoplasm of breast, chronic kidney disease, major depressive disorder, anxiety disorder, and hypertension. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed the resident to have intact cognition. Review of Resident #9's Medication Administration Record (MAR) and Physician orders dated July 2019 revealed morning medications included Losartan potassium (for hypertension) 50 milligrams (mg) orally, Lyrica (for nerve pain) 100 mg orally, Meloxicam (for inflammation)15 mg orally, pantoprazole (for reflux) 40 mg orally, acidophilus supplement capsule one orally, daily-vite(vitamin) one tablet orally, Labetalol (for hypertension) 300 mg orally, and Levothyroxine (for hypothyroidism) 137 micrograms (mcg) orally. Observation on 07/15/19 at 9:25 A.M. of Resident #9 revealed the resident had a cup full of morning medications sitting on her bedside table. Interview on 07/15/19 at 9:30 A.M. with the Director of Nursing (DON) verified Resident #9's morning medications had been left sitting on the resident's bedside table. Review of facility policy titled General Dose Preparation and Medication Administration dated 01/01/13, revealed facility staff should not leave medications or chemicals unattended. The resident should be observed for consumption of the medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on review of nursing staffing schedules and staff interview, the facility failed to ensure eight consecutive hours of Registered Nurse (RN) coverage daily as required. This had the potential to affect all 27 residents currently residing in the facility. Findings include: Review of the facility staffing schedules revealed no RN had been scheduled to work on the following dates, 04/27/19, 04/28/19, 04/29/19, 04/30/19, 05/02/19, 05/04/19, 05/11/19, 05/12/19, 05/25/19, 05/26/19, 06/08/19, 06/09/19, 06/23/19, 06/23/19, 06/29/19, and 07/13/19. Interview on 07/18/19 at 11:30 A.M. with the Director of Nursing (DON) verified the facility did not have a RN working on the above dates. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Based on medical record review, review of personnel records, review of accident logs, staff interview, and review of facility policy and procedure, the facility failed to provide appropriate dementia care, treatment, and training to staff member (State Tested Nurse Assistant (STNA) #135) resulting in a skin tear and a fall for Resident #28. This had the potential to affect all six residents (#11, #12, #16, #24, #28, and #178) on the dementia unit on 05/16/19. The census was 27. Findings include: Review of the medical record for the Resident #28 revealed an admission date of 01/10/18 and a discharge date of 06/21/19 after the resident passed away in the facility. Diagnoses included dementia with behavioral disturbance muscle weakness, high blood pressure, repeated falls, syncope, major depressive disorder, heart disease, chronic obstructive pulmonary disease (COPD), and bipolar disorder. Review of the Minimum Data Set (MDS) assessment completed on 01/11/19 revealed the resident had impaired cognition. The resident required extensive assistance of one staff for transfers, locomotion, toileting and care, and the resident had no skin concerns, but he did have falls. Review of the plan of care, dated 03/28/18, revealed the resident was at risk for falls due to an alteration in self mobility related to impaired coordination and balance, unsteady gait, shortness of breath, and impulsive behaviors. Interventions included bed alarm when in bed, gripper socks and or non-skid foot wear at all times, physical therapy (PT) evaluation due to recent falls and decline in mobility, send to emergency room for evaluation, remove suitcase from room and place in storage, bed in lowest position when in bed. Review of the plan of care, dated 03/28/19 revealed the resident had a cognitive deficit and the potential for mood/behavior problems, he had aggressive and uncontrolled behaviors at times. Interventions included to attempt to redirect with diversion activities, administer medications as ordered, respect the residents space, and engage calmly in conversation, if response is aggressive, staff are to calmly walk away and approach later. Review of the facility incident/accident log for April 2019 through July 2019 revealed no patterns or trends. An incident dated 05/16/19 at 12:20 A.M. revealed STNA #129 and STNA #135 entered Resident #28's room due to his bed alarm sounding. The resident was on the edge of the bed, visibly agitated and verbally abusive and threatening. When the staff asked what he needed, the resident became more aggressive and started swinging and kicking at both staff. The resident walked into the hallway and began exit seeking, when the door wouldn't open, the resident tried to grab and swing at both staff. STNA #135 separated himself from the incident and the resident suddenly charged at STNA #129. STNA #135 stepped in between the two and the resident attempted to punch STNA #135 in the face. STNA #135 grabbed Resident #28's arm to stop him from making contact, which resulted in a small skin tear to the residents right forearm above his wrist. While STNA #135 was still holding onto him, the resident attempted to kick at the aide, causing the resident to lose his balance and staff lowered the resident to the ground. The resident remained on the floor until Emergency Medical Staff and the Sheriff arrived, and he continued the behaviors while at the facility. The resident was transferred to the hospital for an evaluation. A review of the personnel file for STNA #135's revealed he was rehired with the facility on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 0741 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 02/02/19, his most recent Abuse policy training was 04/12/18, most recent Alzheimer's and Dementia training was on 04/12/17, and he was never trained on Alzheimer's Disease Behavior Management. Interviews on 07/17/19 at 5:00 P.M. with the Administrator and the Director of Nursing (DON) confirmed the absence of abuse and neglect training, training regarding Understanding Dementia and Alzheimer's and Alzheimer's Disease Behavior Management, and they further confirmed STNA #135 should have never grabbed Resident #28 which resulted in a skin tear and a fall. They stated STNA #135's last day was the morning of 05/16/19. They further revealed there was no additional information into the incident on 05/16/19 and there was no additional training's completed with any staff after the incident. A review of facility policy titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property dated February 2019, revealed the facility will educate its staff and volunteers upon hire and annually thereafter regarding the facility's policy concerns abuse, neglect, exploitation of residents, and misappropriation of the residents property, and how to respond to resident to resident abuse and injuries of unknown sources. The training will include appropriate interventions to deal with aggressive behaviors and extraordinary reactions of residents to ordinary stimuli, such as an attempt to provide care (i.e. catastrophic reactions), and dementia management and abuse prevention. This deficiency substantiates Complaint Number OH00105640. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview and review of facility policy and procedure, the facility failed to properly store medications in the medication carts. This had the potential to affect all 27 residents receiving medications from the two medication carts. The census was 27. Findings include: An observation on 07/16/19 at 10:15 A.M. of medication cart #1 (storing the front hall residents medications) with Licensed Practical Nurse (LPN) #124 revealed a half white round pill with an 'M' on it, identified as Metoprolol 25 milligrams (mg) in the medication cart drawer. At the time of the observation LPN #124 verified the loose pill in the medication cart. This cart stored the medications for Residents #2, #3, #4, #5, #6, #8, #10, #13, #14, #15, #17, #18, #20, #22, #25, #26, and #27. An observation on 07/16/19 at 10:30 A.M. of medication cart #2 (storing the back hall residents medications) with LPN #124 revealed a yellow round pill with the numbers 159 on one side, identified as meloxicam 15 mg, and a light green round pill with an 'H' on one side and 123 on the other side, identified as Ropinirole Hydrochloride 1 mg in the mediation cart drawer. At the time of the observation, LPN #124 verified the loose pills in the medication cart and indicated the Ropinirole pill did not look familiar to her. This cart stored the medications for Residents #1, #7, #9, #11, #12, #16, #19, #21, #23, and #24. A review of the policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 10/31/16, revealed the facility should ensure that medication and biologicals for each resident are stored in the containers for which they were originally received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 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 365835 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morrow Manor Nursing Center St Rt 314 North Chesterville, OH 43317 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 - Many 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, staff interview, review of dietary menus, and review of facility policy the facility failed to ensure the facility menu was followed. This had to potential to affect 27 residents who received meals from the kitchen. The facility census was 27. Findings include: Review of facility dietary menu for 07/16/19 revealed the meal was to include meat loaf, mashed potatoes, cream corn and a fresh baked roll. Observation of the lunch meal service on 07/16/19 at 12:00 P.M. revealed no fresh baked rolls were served to any of the residents. Interview on 07/16/19 at 12:05 P.M. with Dietary Worker #114 stated the facility stopped ordering the dinner rolls due to there was not enough room in the freezer. Dietary Worker #114 stated the facility has not had dinner rolls for some time. Review of facility policy titled Menus undated, revealed menus shall be written in advance and followed. The Nutrition Professional shall be notified of any permanent menu alterations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365835 If continuation sheet Page 8 of 8