Inspection·October 17, 2023

F 0692 Level of Harm - Actual harm Residents Affected - Few difficulty. Inadequate fluid intakes were related to resident doesn't know to drink fluids as will just hold cups. Additionally, fluid intakes do not meet 100% estimated fluid needs. Continue with regular pureed diet with honey thickened liquids. Will add magic cup three times daily and honey thickened facility nourishment three times daily. Goals are for no signs or symptoms of dehydration, no difficulty with chewing or swallowing, and no significant weight change. Review of a nursing alert progress note dated 09/18/23 revealed Resident #58 ate less than 50% over the last three shifts. Inadequate fluid intake, swallowing difficulty related to recent CVA (stroke) as evidenced by need for mechanically altered diet. Inadequate fluid intakes related to resident doesn't know to drink fluids and will just hold cups as evidenced by fluid intakes do not meet 100% estimated fluid needs. Continue with a regular pureed diet with honey thickened liquids. Review of e-mail correspondence dated 09/18/23 revealed Case Manager (CM) #250 communicated to Registered Dietitian (RD) #200 and therapy that Resident #58 had consumed less than 50% of her meals for several days. RD #200 responded Resident #58 was on multiple supplements and weight was stable since admission. Review of a physician communication form dated 09/19/23 revealed nursing notified Physician Assistant (PA) #300 Resident #58's oral intake was inadequate. Gags with pureed food but ok with magic cup and pudding. PA #300 responded on 09/20/23 and indicated resident was followed by speech therapy and have dietitian see for further recommendations. Review of State Tested Nurse Aide (STNA) documentation revealed on 09/20/23 and 09/22/23, fluid intakes were documented as either resident refused or not applicable. There was no documentation Resident #58 received any fluids on those dates. Review of STNA documentation dated 09/21/23 revealed Resident #58 had consumed 480 ml (approximately 16 ounces) of fluids. Review indicates the resident did not have adequate fluid intake for three days. Review of a physician communication form dated 09/21/23 revealed RD #200 notified PA #300 Resident #58 disliked the facility nourishment and threw it at the nurse. The nurse tried Boost Breeze with the resident and the resident drank that. RD #200 recommended Boost Breeze, eight ounces two times daily. PA #300 responded on 09/22/23 and ordered Boost Breeze as recommended. Review of a nursing alert note dated 09/21/23 revealed Resident #58 ate less than 50% over the last three shifts. Speech therapist and dietitian are working with patient. Has appropriate supplementation ordered. No weight loss noted since admission. Further review of a nursing progress note dated 09/21/23 revealed Resident #58 was alert to self, post CVA. Right side has no movement. Medications crushed. Refusing meals, drinking some juice. Incontinent of bladder and bowel. Additional review of a nursing progress note dated 09/23/23 at 9:45 A.M. revealed Resident #58 had noted increased drowsiness and weakness, aggressive when writer tried to give her medicine. Vital signs taken and blood pressure (BP) was 90/30, temperature 97.8, Pulse 96, and oxygen saturation (SpO2) 95%. Resident does not answer appropriately due to previous CVA. Notified physician (MD) and order received to send to the hospital. Attempted to call daughter, number cannot be reached. Resident picked up at 9:40 A.M. Report given to emergency room (ER) nurse. Review of a hospital History and Physical, dated 09/23/23, revealed emergency medical services (EMS) reported the resident had altered mental status and failure to thrive at the facility. Resident was lethargic on arrival and hypotensive. EMS stated the resident had no food or water in a couple of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365896 If continuation sheet Page 2 of 4 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 365896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Run Manor 11745 Township Road 145 Findlay, OH 45840 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 0692 Level of Harm - Actual harm Residents Affected - Few days. Additionally, Resident #58 now had altered mentally so they decided to send her to the Emergency Department (ED). Resident #58 had acute encephalopathy (alteration of mental status), severe sepsis with hypotension (likely due to significant dehydration), severe dehydration due to no oral intake of food/water for the last three days (reported), significant hypernatremia (likely due to dehydration and leading to altered mental status), acute kidney injury on top of chronic kidney disease, mild acute respiratory failure with hypoxemia due to COPD exacerbation, and mild COPD exacerbation with unknown trigger at this time. Physical examination revealed the resident had a very dry tongue and oral mucosa (the mucus membrane or skin inside the mouth, including cheeks and lips). Resident #58 was admitted to the intensive care unit for closer monitoring of oxygen levels, regular diet started, daily weight and strict input and output, ED given boluses, continue Intravenous (IV) one-half normal saline (NS) at 75 milliliters/hour (ml/hr.), doing no antibiotics now as there is no evidence of infection. Lastly, furomeside (diuretic) was discontinued. Review of hospital consultation notes dated 09/23/23 revealed Resident #58 was admitted to the hospital due to acute kidney injury, hypernatremia (high concentration of sodium in the blood), acute encephalopathy (alteration of mental status), hypotension (low blood pressure), severe sepsis, hyperkalemia (high potassium), and dehydration. Additional review revealed resident admitted with report of more than two days of poor oral intake of food and water. Treatment included dextrose 5 percent in water IV solution 1,500 milliliters (ml) 150 milliliters/hour (ml/hr) and sodium chloride 10 ml IV push two times daily. Further review of the medical record revealed no evidence Resident #58 was assessed for dehydration signs and symptoms prior to hospitalization. Interview on 10/16/23 at 2:07 P.M. with PA #300 revealed she recalled a conversation with someone at the facility about supplements for Resident #58. She did not specifically recall a conversation about fluid intakes. PA #300 stated she knew the resident's intakes were poor, but she was unaware the resident had not consumed any fluids on 09/20/23 and 09/22/23 and had only had 420 ml (16 ounces) on 09/21/23. PA #300 stated she saw Resident #58 on 09/20/23, but the resident was on transmission-based precautions, so she only saw her from the door and did not physically examine her. PA #300 stated she did not recall any specific concerns related to Resident #58's fluid intakes, noting the facility wanted her to back them but she did not remember notification of fluid concerns. PA #300 stated she probably would have discontinued Resident #58's furomeside if she had known the resident's fluid intakes were that low. Interview on 10/16/23 at 2:24 P.M. with CM #250 revealed she had a conversation with PA #300 about a supplement for Resident #58 due to poor meal intakes. No changes were made because the dietitian stated the resident's weight was stable. CM #250 confirmed the communication with PA #300 was related to poor meal intakes and not inadequate fluid intakes. Interview on 10/17/23 9:41 A.M. with Corporate Nurse (CN) #275 revealed Resident #58's vital signs had been monitored two times daily and had been stable up to the day the resident was sent out to the hospital. CN #275 stated Resident #58 had stable pulses and BP and there were no outwardly signs of obvious dehydration. The facility had been trialing some different things to increase the resident's intakes. CN #275 stated Resident #58 refused meals, fluids, care, and would become aggressive toward staff. CN #275 stated based on Resident #58's presentation, the staff were doing whatever they could and did what they needed to do. Additionally, CN #275 stated Resident #58 was on a pureed diet, and while she could not measure the amount of fluid in pureed diets, Resident #58 was receiving fluids through meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365896 If continuation sheet Page 3 of 4 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 365896 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Run Manor 11745 Township Road 145 Findlay, OH 45840 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 0692 Level of Harm - Actual harm Residents Affected - Few Interview on 10/17/23 at 10:19 A.M. of Registered Dietitian (RD) #200 revealed Resident #58 had been discussed at the facility's weekly nutrition at risk meetings. RD #200 stated Resident #58 refused meals and fluids and would hit staff. RD #200 stated all foods contain a certain percent of water, based on the food, and it was possible Resident #58 received enough fluids to sustain her through a pureed diet. RD #200 stated she would review the meals and Resident #58's intakes to calculate an estimate of fluids the resident would have received from eating a pureed diet. Follow up interview on 10/17/23 at 12:03 P.M. with PA #300 revealed she may have been remembering the wrong resident when she spoke with this surveyor on 10/16/23. PA #300 stated she was now retired, working off of memory, and could not recall all of the details. PA #300 stated she had the resident confused with another resident and she did actually evaluate Resident #58 on 09/20/23 and had no concerns related to dehydration. While PA #300 stated she was notified by the facility on 09/19/23, Resident #58 had poor oral intakes, she believed that to mean the resident was drinking low liquids, not no liquids, which was why she deferred to the dietitian. Additionally, on 09/21/23, PA #300 stated she ordered Boost Breeze, and that was a fluid. PA #300 confirmed she was unaware Resident #58 had only consumed one - eight ounce Boost Breeze on 09/21/23 and none on 09/22/23. While some fluids could be obtained through foods, she was uncertain if it would be a sufficient amount to prevent dehydration. PA #300 verified furomeside would increase the risk of dehydration, especially in someone who was not consuming sufficient fluids, and she did not know why that was not addressed for Resident #58. Follow-up interview on 10/17/23 at 2:45 P.M. with CN #275 confirmed while Resident #58's vital signs were stable in the days leading up to her hospitalization, there was no evidence of nursing assessment for other indicators of dehydration, including sunken eyes, skin turgor, or oral mucosa. Interview on 10/18/23 at 9:24 A.M. with RD #200 verified she was not in the kitchen when Resident #58's meals were prepared and was unable to verify if the proper amounts of fluid was added to the resident's pureed meals and/or served to the resident. Review of facility policy titled, Hydration Policy, approved 03/17/16, revealed the facility will provide each resident with sufficient fluid intake to maintain proper hydration status. Sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates. This deficiency represents non-compliance investigated under Complaint Number OH00146850. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365896 If continuation sheet Page 4 of 4