Health inspection·January 2, 2020

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete chek was 385 and on 12/26/19 her accu-chek was 386. She verified in the nursing notes there was no evidence of any documentation the physician was notified per the physician's order of the accu-cheks being above 350 on 12/09/19 and on 12/26/19. Review of facility policy titled, Change in a Resident's Condition or Status dated May 2017 revealed the facility would promptly notify the physician of changes in the resident's medical condition. The nurse was to notify the resident's attending physician when there was a specific instruction to notify the physician. Event ID: Facility ID: 365902 If continuation sheet Page 2 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to ensure Resident #20's wheelchair was maintained in safe condition. This affected one of 28 residents observed for environment. The facility census was 28. Findings include: Resident #20 was admitted to the facility on [DATE] with diagnoses including heart failure, morbid obesity and diabetes mellitus type two. Review of the Plan of Care with an initial date of 08/08/19 revealed he was at risk for skin breakdown due to his morbid obesity and diabetes mellitus type two. The Minimum Data Set assessment (MDS) dated [DATE] revealed he had cognitive impairment, needed limited assistance of one person for bed mobility and transfers and extensive assistance of one person for toileting, dressing and hygiene. He was able to move on an off the unit using his wheelchair. Observation was conducted on 12/30/19 at 9:26 A.M. of Resident #20 sitting in the hallway. The right arm of his wheelchair was missing the padded covering exposing the bare metal. There were two metal pins approximately 1/3 inch in diameter and half an inch long protruding out of the arm rest and leaving multiple indents in the skin of his right arm. Activity Director (AD) #900 was passing by at 9:46 A.M. and verified the right arm rest was missing the padding. AD #900 said she was unaware it was broken. Resident #20 interjected it had been like that for one month. Observation and interview was conducted on 12/31/19 at 8:57 A.M. to 9:10 A.M. with Resident #20. The right arm rest padding was still missing. The metal pins were digging into his arm leaving multiple circular indents in the shape of the pin head. This was verified with the Administrator at 8:58 A.M. The Administrator added Resident #20 was supposed to be getting a new chair from Hospice due to his tendency to slide forward in his current chair. At 9:10 A.M. the Administrator found a replacement handle from a spare wheelchair in storage at the facility and fixed the wheelchair arm rest for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 3 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of policy the facility failed to develop a baseline care plan with the minimum necessary mental health information for Resident #181. This affected one (Resident #181) of one resident reviewed for baseline care plan. Findings include: Resident #181 was admitted to the facility on [DATE]. His diagnoses included paranoid schizophrenia, chronic post-traumatic stress disorder, recurrent major depressive disorder, generalized anxiety disorder, and mild cognitive impairment. Review of physician orders dated 12/20/19 revealed the resident was to receive trazodone (antidepressant) 25 milligrams (mg) daily for insomnia and Clozaril (antipsychotic) 100 mg twice a day for schizophrenia. Review of physician orders dated 12/21/19 revealed citalopram (antidepressant) 10 mg daily for depression was added. Review of the Ohio Department of Mental Health Pre-admission Screen and Resident Review (PASRR) Determination for Resident #181 revealed a list of information important for the facility to know about the resident's needs which included diagnoses of schizophrenia, paranoid type, anxiety, post-traumatic stress disorder, major depressive disorder, cognitive disorder, a labile (irregular) mood with irritability, limited insight and judgment, poor memory, and early signs of increased symptoms including increased paranoia. Listed information of services the facility would need to provide for Resident #181 included occupational therapy evaluation, physical therapy evaluation, education regarding medication compliance and/or side effects, mental health counseling, and an ongoing evaluation of the effectiveness of current psychotropic medications and target symptoms. Review of the baseline care plan dated 12/19/19 revealed Resident #181 was to remain in the facility, had normal vision with glasses, was a diabetic, received insulin with blood sugars, ate in the dining room, was independent with bed mobility, transfers, walking, toileting, locomotion, eating, grooming, hygiene and bathing, and was continent of bowel and bladder. There was no information found in the baseline care plan related to Resident #181's mental illness or PASRR Determination. Interview on 01/02/20 at 12:59 P.M. with Licensed Practical Nurse (LPN) #361 indicated pertinent diagnoses, doctors orders, and PASRR information should be included in baseline care plans, and verified Resident #181's baseline care plan did not include information related to his mental illness or the results of his PASRR Determination. Interview on 01/02/20 at 4:14 P.M. with Social Worker #360 revealed Resident #181 was scheduled to begin mental health counseling services on 01/03/20. Social Worker #360 verified mental health information and PASRR Determination information was not included in Resident #181's baseline care plan. Review of facility policy entitled, Care Plans - Baseline, revised December 2016, revealed the Interdisciplinary Team will review the healthcare practitioner's orders (e.g. dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission order; physician orders; dietary orders; therapy services; social services; and PASARR recommendation, if applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 4 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure they monitored frequency of bowel movements, and developed and implemented a bowel management protocol to prevent constipation for Resident #21. This affected one (Resident #21) of one resident reviewed for constipation and had the potential to affect all 29 residents currently residing in the facility. Residents Affected - Few Findings include: Review of medical record for Resident #21 revealed an admission date of 10/22/19 and diagnoses included morbid obesity, diabetes, pressure ulcer of the sacral region, muscle weakness, and constipation. Review of an admission five-day minimum data set (MDS) dated [DATE] revealed Resident #21 had intact cognition. She was totally dependent on one person for bed mobility and transfers occurred only once or twice with two person assist. She was unable to ambulate. She was totally dependent on two persons with toileting and was always continent of the bowel. Review of care plan dated 10/31/19 revealed Resident #21 had the potential for constipation related to decreased mobility, and medication side effects. Interventions included to follow the bowel protocol for bowel management, monitor, document, and report signs and symptoms related to constipation to the physician, and record bowel movement pattern each day describing the amount, and consistency. Review of a nursing note dated 11/19/19 at 5:52 P.M. revealed Resident #21 stated she had not had a bowel movement in a few days. Her abdomen was mildly distended and bowel sounds were present. She denied pain. She received Colace one 100 milligram (mg) capsule per an as needed order. The physician was contacted and ordered a Dulcolax suppository (rectal) 10 mg every 24 hours as needed for constipation. Review of current physician orders for December 2019 revealed Resident #21 had an order for a Dulcolax suppository 10 mg, insert one every 24 hours as needed for constipation, docusate sodium (Colace) capsule 100 mg by mouth every 12 hours as needed for stool softener and monitor defecation (bowel movements) every day and evening shift. Review of the Medication Administration Record (MAR) for December 2019 revealed bowel movement monitoring for Resident #21 as follows: On 12/13/19 she had two bowel movements and no size was recorded, on 12/19/19 she had one small bowel movement, and on 12/27/19 she had a large and a medium bowel movement. There was no evidence of documentation per the MAR from 12/14/19 to 12/18/19 (four days) and none from 12/20/19 to 12/26/19 (six days) that indicated Resident #21 had a bowel movement. Review of the MAR for December 2019 revealed Resident #21 did not receive any docusate sodium 100 mg capsules every 12 hours as needed for a stool softener or any Dulcolax suppository 10 mg every 24 hours as needed for constipation for the month of December 2019. Interview on 12/31/19 at 10:41 A.M. with the Director of Nursing (DON) revealed the nurses were expected to document Resident #21's bowel movements in the MAR. She verified per documentation Resident #21 did not have a bowel movement from 12/14/19 to 12/18/19 (four days) and from 12/20/19 to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 5 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 Level of Harm - Minimal harm or potential for actual harm 12/26/19 (six days). She verified Resident #21 was not administered any as needed medications to prevent constipation for the month of December 2019. She revealed the facility did not have a specific bowel protocol or policy in place instead it was up to each nurse to check the bowel patterns per the MAR and administer as needed medication as ordered. She verified the nurses should have assessed and provided interventions to prevent constipation from 12/14/19 to 12/18/19 and from 12/20/19 to 12/26/19. Residents Affected - Few Interview on 12/31/19 at 10:47 A.M. with Resident #21 revealed she had issues with constipation as it was hard to have a bowel movement at times and she went several days without having a bowel movement which caused discomfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 6 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, record review and review of policy the facility failed to ensure lab work was completed per physician orders. This affected two residents (Resident #3 and Resident #16) out of six residents reviewed for hydration (fluid overload) and unnecessary medications. The facility census was 28. Residents Affected - Few Findings included: 1. Review of the medical record for Resident #3 revealed his admission date was 09/12/14 and diagnoses included hypertension, schizoaffective disorder, acute kidney failure, atrial fibrillation, hyperlipidemia, chronic obstructive pulmonary disease, and fluid overload. Review of the care plan dated 09/12/19 revealed Resident #3 had hypertension related to fluid overload and history of alcohol dependence. Interventions included to obtain blood pressure readings and weight per facility policy. Review of the care plan dated 09/12/19 revealed Resident #3 had acute renal failure with fluid overload. Interventions included fluids as ordered, monitor lab reports of electrolytes, report results to physician, and notify physician of a potassium level above 5.5. Review of a quarterly Minimum Data Set (MDS) 3.0 dated 12/08/19 revealed Resident #3's cognitive status was unable to be assessed as he refused to participate. He required supervision with bed mobility, transfers, walking, and eating. Review of physician orders for December 2019 revealed Resident #3 had lab orders with an order date of 12/03/18 for a basic metabolic panel (BMP/electrolytes) a hemoglobin A1C (a level to monitor the average blood sugar levels over the past three months) a lipid panel (testing of cholesterol and other lipids to help monitor risk of heart disease) and a lithium level (drug level of lithium for treatment of bipolar disorder) every three months (March, June, September, and December). Resident #3 had an order dated 12/03/18 for a blood urea nitrogen level (BUN) (a level that tests how much urea was in the blood and if the kidneys are removing the urea and the status of kidney function) and a creatinine level (reflects the amount of creatinine in the blood and the status of kidney function) every three months (March, June, September, and December). Review of the medical record from 01/01/19 to 01/02/20 revealed Resident #3 had the following lab result records: on 01/11/19 a comprehensive metabolic panel (CMP) was completed that was within normal limits. He did not have any record of any further basic metabolic panels, hemoglobin A1C, lipid panels, lithium levels, or blood urea nitrogen levels except on 01/11/19 as part of the CMP (the result was 13) which was within normal limits and a creatinine level on 01/11/19 as part of the CMP which was also within normal limits. He received complete blood count (CBC) levels monthly or as ordered per the record. Observation of Resident #3 on 12/30/19 at 5:02 P.M. revealed after he consumed a glass of milk, juice and coffee at dinner, he went to his room and consumed two large Styrofoam cups full of water. Interview with the Director of Nursing (DON) on 12/31/19 at 2:50 P.M. verified Resident #3 had physician orders for lab work that included a BMP, hemoglobin A1C, lipid panel, lithium level, BUN, and creatinine level every three months since 12/03/18. She verified within the last year the only lab (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 7 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that was completed regarding those orders was a CMP completed on 01/11/19. She verified Resident #3 received lithium 300 milligrams capsule by mouth two times a day for schizoaffective disorder and this medication should be monitored with a routine medication level that had also been ordered. She verified Resident #3 had diagnoses of hypertension, kidney failure, and hyperlipidemia that should be monitored with lab levels that had been ordered. She verified he also had a diagnoses of fluid overload as he consumed increased quantities of fluids and his lab levels should be monitored per orders as indicated in the care plan. She stated it was apparent they had a system failure and she was not sure why the labs were not getting done as ordered. 2. Review of medical record for Resident #16 revealed an admission date of 05/01/13 and diagnoses of dementia with behavioral disturbances, schizoaffective disorder, hyperlipidemia, long term drug therapy, and hypotension. Review of physician orders for December 2019 for Resident #16 revealed she had the following lab orders that included: a liver panel every three months (January, April, July, and October) that was ordered on 12/03/18, a Vitamin D level, a Depakote level, a lipid panel, and a hemoglobin A1C level every three months (February, May, August, and November) that were ordered on 12/03/18. Review of physician orders for December 2019 revealed Resident #16 received Depakote extended release 250 mg, give one tablet by mouth two times a day for seizure control, Depakote tablet delayed release 500 mg at bedtime for seizure activity, and Vitamin D2 tablet give 50,000 units by mouth one time a day every Wednesday as a supplement. Review of the medical record from 01/01/19 to 01/02/20 revealed Resident #16 had the following lab results in her chart: A liver panel dated 07/22/19 was completed. There were no other liver panel results found in the record and the it was ordered to be done every three months. A Depakote level dated 03/04/19 was 83.5, and on 09/02/19 a level was completed and was 77 within normal limits. There was no Depakote level found in the record for January 2019 or June 2019. There was no record found to evidence Vitamin D, hemoglobin A1C, and lipid panel levels were obtained during this time period and these were ordered to be done every three months. Interview with the DON on 12/31/19 at 2:50 P.M. verified Resident #16 had physician orders to receive lab work that included a liver panel, vitamin D, Depakote level, lipid panel, and hemoglobin A1C every three months. She verified Resident #16's lab work was not completed per orders. She verified Resident #16 received Depakote and Vitamin D and a drug levels of these should be monitored to ascertain their effectiveness. She stated it was apparent they had a system failure and she was not sure why the labs were not getting done as ordered. Review of facility policy titled, Lab and Diagnostic Test Results- Clinical Protocol dated November 2018 revealed the physician would identify and order diagnostic lab testing and monitor the residents needs. The facility staff was to process the test requisitions and arrange for the tests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 8 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and review of policy the facility failed to ensure proper hand hygiene was completed while changing Resident #19's wound dressings. This affected one resident (Resident #19) out of two residents observed for dressing changes. Residents Affected - Few Findings include: Review of the medical record for Resident #19 revealed an admission date of 06/21/19 and diagnoses that included diabetes, chronic kidney disease, spinal stenosis, and Methicillin Resistant Staph Aureus infection (MRSA) of the left posterior leg wound. Review of a care plan dated 09/03/19 revealed Resident #19 had a potential for and actual pressure injury, surgical wound, rashes, cellulitis, skin tear, and vascular wounds related to difficulty walking, reduced mobility and diabetes. Resident #19 had an abrasion to her left lower lateral leg, a blister to the left lower proximal leg, and an open area to her toe. Interventions included administer treatments as ordered and monitor effectiveness, and to be seen by a wound consultant as needed. Review of a quarterly minimum data set (MDS) dated [DATE] revealed Resident #19 had impaired cognition and required supervision with bed mobility and limited assistance of one person with transfers. She was unable to ambulate. She was at risk for pressure ulcers but had no pressure ulcers on admission. Review of physician orders per the wound clinic dated 12/17/19 revealed Resident #19 had non-healing ulcers and an infection of her left leg and toes. The wound clinic ordered lab work including a culture and sensitivity of her left posterior leg wound. Review of a laboratory report dated 12/17/19 for Resident #19 revealed her left leg wound culture identified a Methicillin Resistant Staph Aureus (MRSA) infection. Review of physician orders for December 2019 revealed Resident #19 had an order for Bactrim double strength (antibiotic) tablet 800-160 milligram (mg) one tablet by mouth two times a day for MRSA of the wound to be given for seven days. This was ordered from 12/24/19 at 8:00 P.M. to 12/31/19 at 8:00 A.M. Review of physician orders for December 2019 revealed Resident #19 had the following treatment orders: Cleanse her left third toe with normal saline and apply silver sulfadiazine cream one percent to skin tear, cover with dry gauze and secure with tape, cleanse the left great toe with normal saline, and apply silver sulfadiazine cream one percent to the left great toe callous area, cover with dry gauze and secure with tape, cleanse the left lateral lower leg with normal saline, apply silver sulfadiazine cream one percent to wound bed, cover with dry gauze, secure with rolled gauze and apply ace wrap from knee to toes to prevent edema, and cleanse lateral proximal left lower leg with normal saline, apply silver sulfadiazine cream one percent, cover with gauze, secure with rolled gauze and apply ace wrap from knee to toes for edema control. Observation of Registered Nurse (RN) #600 on 12/31/19 at 9:37 A.M. completing Resident #19's dressing changes revealed RN #600 washed her hands and applied gloves. She removed the dressings to Resident #19's left lower leg and a dressing to her left great toe. There was not a dressing on her left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 9 of 10 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/02/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor 3090 Five Points Hartford Fowler, OH 44418 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few third toe. RN #600 removed her gloves and washed her hands. She applied a new pair of gloves. She then cleansed Resident #19's left lateral lower leg, left proximal lower leg, left great toe and left third toe. RN #600 did not remove her gloves or wash her hands in between cleansing of each wound area. After cleansing each wound, she removed her gloves and washed her hands and applied a new pair of gloves. She then applied silver sulfadiazine cream one percent to Resident #19's left lateral lower leg, left proximal lower leg, left great toe and left third toe. She used the same pair of gloved hands to apply the silver sulfadiazine cream to all the areas and did not wash her hands and apply new gloves between each wound. She then applied a four by four dressing to the left lower leg wounds and wrapped the area with gauze. She then applied a four by four dressing to her left great toe and taped the area. She wrapped Resident #19's left leg with an ace wrap per order. RN #600 then removed her gloves and washed her hands. Interview with RN #600 on 12/31/19 at 9:49 A.M. verified she cleansed all Resident #19's wounds at the same time not washing her hands or applying new gloves in between each wound. She verified she applied the silver sulfadiazine cream to each wound using the same pair of gloves and did not wash her hands between each wound. She verified Resident #600's left lower proximal leg wound was being treated with antibiotics for a MRSA infection per the culture report. She verified not washing her hands between each wound caused increased potential for cross contamination. Interview with the Director of Nursing on 12/31/19 at 10:40 A.M. verified RN #600 should not have cleansed all of Resident #19's wounds without washing her hands in between each wound. She also verified RN #600 should not have applied silver sulfadiazine cream to each of the wounds using the same pair of gloves and not washing her hands between each wound. She verified Resident #19 had MRSA in her left lower proximal leg wound and was receiving antibiotic therapy per the wound clinic recommendations. She verified not washing her hands and changing gloves between each wound caused increased risk of cross contamination. Review of facility policy, Dressing, Dry/ Clean that was revised August 2011 revealed the purpose was to provide guidelines for the application of a dry, clean dressing. The policy did not specify to not cleanse two or more wounds at the same time without performing hand hygiene between each wound or did not specify in the policy not to apply the same cream or treatment to two or more wounds without performing hand hygiene between application of the treatment. The policy did not specify to complete wound care separately for each area when performing dressing changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 10 of 10