Inspection·May 1, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview, review of a investigation, and review of the facility policy, the facility failed to ensure residents were not physically restrained in a wheelchair. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72. Residents Affected - Few Findings include: Review of the medical record for Resident #39 revealed an admission date of 07/11/22. Diagnoses included dementia with agitation, anxiety, and psychotic disorder with hallucination. Review of the Minimum Data Set (MDS) assessment 02/13/25 revealed Resident #39 had moderate impaired cognition, did not exhibit behaviors during the review period, dependent on staff for toileting, and required substantial to maximal assistance from staff for mobility. Resident #39 had a restraint and it was a wander or elopement alarm and it indicated used less than daily. Review of the plan of care dated 04/02/25 revealed Resident #39 was at risk for wandering or elopement with interventions including the resident will not leave facility unattended, the resident's safety will be maintained, engage the resident in purposeful activity, and identify if there is a certain time of day wandering or elopement attempts occur. Review of the investigation for Resident #49 revealed on 04/16/25, the situation was during shift report, night shift reported that Resident #49 was restless, hallucinating and combative. The resident was crawling out of bed and attempting to stand or walk. Night shift staff reported the resident was brought to the nursing station for increased monitoring. After the night shift change report, and first shift began working with residents, it was noted that the resident was in the wheelchair with a gait belt wrapped around the wheelchair arms to prevent the resident from falling or standing up again. A CNA immediately removed the gait belt. Unit Manager and or designee notified the resident's family and Medical Director. Medical Director gave orders for labs if no labs have been drawn in the past six weeks. Licensed Social Worker or designee assessed residents' psychosocial well-being with no concerns. Interview on 05/01/25 at 5:45 A.M. with Certified Nursing Assistant (CNA) #122 stated there was an incident involving Resident #39 which occurred one night (04/16/25) when Resident #49 almost fell out of the wheelchair. CNA #122 verified after Resident #49 stood up from the wheelchair, a gait belt was placed on the front arms of the wheelchair to keep Resident #49 safe from getting hurt when trying to stand up. CNA #122 verified at the time this occurring, it was not meant to be harmful but helpful and did not know it was wrong to do this. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 365896 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 05/01/2025 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)