Health 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. Page 1 of 5 365896 365896 05/01/2025 Fox Run Manor 11745 Township Road 145 Findlay, OH 45840

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when informed CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. Resident #49 was not harmed, and CNA #122 was suspended until the investigation was concluded. Review of the employee file for CNA #122 revealed the date of hire of 08/23/24. There was a disciplinary action due to performance and or conduct. The discipline dated 04/16/25 was for carelessness in performance of job duties, observance to safety rules or disregard of common safety practices or failure to use Personal Protective Equipment. The employee was suspended pending investigation. Review of the facility's policy titled Restraint Policy dated 2016 revealed the resident has the right to be free from any physical or chemical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. Residents shall not be restrained unless restraints are authorized by a physician in writing, used in an emergency, or requested by an alert oriented resident or representative of the risks and benefits associated with restraint use so that the choice is an informed one. The definition of a restraint are physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot move easily, which restricts freedom of movement or normal access to one's body. Physical restraints are not defined by the device used, but rather by the impact the device had on the resident's freedom of movement, functional status and quality of life. This deficiency represents non-compliance investigated under Complaint Number OH00165184. 365896 Page 2 of 5 365896 05/01/2025 Fox Run Manor 11745 Township Road 145 Findlay, OH 45840

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. Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and review of the facility policy, the facility failed to report an allegation of abuse when a resident was found to be physically restrained by a gait belt in her wheelchair to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72. 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 facilities 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. Review of the SRIs revealed there was no allegation of abuse reported to the State Survey Agency involving Resident #39 being found physically restrained by a gait belt to her wheelchair. 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. Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when they were informed that CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. The Administrator verified this allegation of abuse was not reported to the Ohio Department of Health. The Administrator explained he did not feel this was done to be abusive. Resident #49 was not harmed, and the staff member was suspended until investigation was concluded. Review of the policy titled Abuse, Neglect, Injuries of Unknown Origin and or Misappropriation of Resident Property revealed the definition which included as the willful act of of unreasonable confinement resulting in mental anguish. The administrator or designee will notify Ohio Department of Health of all alleged violations as soon as possible, but in no event later then twenty-four hours from the time of incident was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00165184. 365896 Page 3 of 5 365896 05/01/2025 Fox Run Manor 11745 Township Road 145 Findlay, OH 45840

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure urinary catheter care was performed with proper infection control procedures. This affected one (Resident # 42) of three residents reviewed for catheter care. The facility census was 72. Findings include: Review of the medical record for Resident #42 revealed admission date of 11/05/24. Diagnoses included malignant neoplasm of bladder obstructive and reflux uropathy, urinary tract infection, infection and inflammatory reaction to catheter and methicillin resistant staphylococcus aureus. Review of the physician's orders dated 04/05/25 revealed an order for an indwelling catheter care every shift. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition, had impaired bilaterally lower extremities, dependent on staff for toileting, and had an indwelling catheter. Review of the plan of care dated 04/11/25 revealed the indwelling catheter was due to uropathy with interventions including provide catheter care per order and as needed. Observation of catheter care on 05/01/25 at 11:40 A.M. revealed Certified Nurse Assistant (CNA) #136 was providing catheter care to Resident #42. CNA #136 gathered a basin of warm water, three washcloths, one towel and liquid wash solution. CNA #136 placed the washcloths in the basin, took one washcloth out of the basin, and placed the liquid wash solution on the washcloth. CNA #136 cleaned the tube of the catheter which had a moderate amount of yellow film. CNA #136 then placed the used washcloth back into the basin and took out another washcloth from the now contaminated water basin and rinsed the soap off from the catheter. This second used washcloth also was placed back into the contaminated basin. CNA #136 took out the washcloth previously used to clean the tubing out of the contaminated water basin, placed liquid wash solution on it, and cleaned around the end of the penis. The used washcloth was placed back into the basin and the washcloth used to rinse the tubing was taken out of the contaminated water basin and used it to rinse around the penis. CNA #136 dried of the penis and tubing with the towel. Interview with CNA #136 on 05/01/25 at 11:58 A.M. verified they placed the washcloths back into the basin which contaminated the water, continued to use and reuse two of the washcloths from the contaminated basin, and only used two of three washcloths that were originally placed into the basin. Interview on 05/01/25 at 12:15 P.M. with the Regional Nurse #200 verified the facility had some issues with the CNAs using washcloths in the basin and placing them back into the basin which contaminated the water. The CNAs have been redirected several times to bring in a bag to place the dirty washcloth in and to not place it back into the basin. Review of the facility's policy titled Indwelling Catheter dated 11/13/17 revealed a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Residents who are incontinent of bowel 365896 Page 4 of 5 365896 05/01/2025 Fox Run Manor 11745 Township Road 145 Findlay, OH 45840

F 0690 Level of Harm - Minimal harm or potential for actual harm or bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Complaint Number OH00165263. Residents Affected - Few 365896 Page 5 of 5