Health inspection·October 9, 2024

F 0661 and silver and calcium alginate and cover with dry dressing. Level of Harm - Minimal harm or potential for actual harm Review of the physician treatment orders dated 08/28/24 revealed Resident #27 had an order to cleanse right hip with twenty-five percent Dakins, apply skin preparation to outer edges of wound. Pack with silver alginate and cover with dry dressing. Residents Affected - Few Review of the progress note dated 08/28/24 revealed the resident was sent home via personal vehicle with a seven day supply of medication and palliative care. Review of physician orders dated 08/29/24 revealed an order for Resident #27 to be discharged home. Review of the facility document titled IDT Discharge Summary V-2 dated 08/27/24 and provided by the Administrator revealed under section B1 Treatments it was indicated the resident had a pressure ulcer to his sacrum and for a right hip wound the type was listed as other. There were no measurements listed and treatments said to see orders. Under section C Appointments there were no names, phone numbers or date/time of follow up appointments listed for continuation of care after discharge. Under the Physical Therapy section it was indicated N/A for physical therapy and stated resident has specialty equipment at home, but no specific equipment was listed such as the air mattress that was recommended in the Physical Therapy Discharge Summary. At the bottom of the last page (page eight) was written 08/12 met with resident concerning discharge. Resident did not want any services. Stated I already have help in place. This was signed by the Administrator. There was no signature from the resident on this document, and this document was in the electronic medical record. Review of a second facility document provided to the surveyor and titled IDT-Discharge Summary V-2 dated 08/27/24 (this was provided after the first IDT Discharge Summary V-2 from the electronic medical record) and revealed under section B1 Treatments it was indicated the resident had a pressure ulcer to his sacrum and the right hip area wound type listed as other. There were no measurements listed and treatments said to see orders. Under section C Appointments there were no names, phone numbers or date/time of follow up appointments listed for continuation of care after discharge. Under the Physical Therapy section it was indicated N/A for physical therapy and stated resident has specialty equipment at home, but no specific equipment was listed such as the air mattress that was recommended in the Physical Therapy Discharge Summary. On the last page (page eight) there was a signature from the resident dated 08/28/24 instead of the written statement from the Administrator as noted prior. This discharge summary was located from the paper hard chart and did not have an attached list of treatment orders for his wound care. Interview on 10/08/24 at 2:30 P.M. with the Director of Nursing (DON) revealed the facility was to verify if the resident was safe for discharge. Resident #27 threatened to leave against medical advice so the facility had to provide a quick discharge. Interview on 10/08/24 at 3:31 P.M. with Social Service Designee (SSD) #309 revealed no referrals were made by the facility for wound care or other home-based services on the Discharge Summary because Resident #27 left before discharge plans were put in place. SSD #309 stated the Administrator was the interim social worker before SSD #309 started at the facility two months ago. SSD #309 said the Administrator met with Resident #27 on 08/12/24 to discuss discharge but did not document in the progress notes. SSD #309 stated Resident #27 had stated to the facility he had planned for wound care and nurse assistance at home so the facility did not follow up with wound care needs and nurse care needs for discharge home. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/08/24 at 3:36 P.M. with the DON revealed Resident #27 did not give the name of his preferred wound care provider or nurse provider, therefore the facility did not follow up or make arrangements for wound care needs at discharge. Interview on 10/09/24 at 8:23 A.M. with Resident #27's mother, who was his primary contact, revealed Resident #27 did not have wound care or nurse care set up at home after discharge so he was going to have to do his own wound care. Interview on 10/09/24 at 11:00 A.M. with Occupational Therapist #338, who worked with Resident #27, revealed Resident #27 wound not be able to care for his wounds on his own at home. Interview on 10/09/24 at 11:34 A.M. revealed the Administrator verified she did not document discharge planning in the electronic medical record progress notes while acting as the interim social service designee but did document in her personal notebook which was not part of the legal medical record. The Administrator also verified the paper copy of the Discharge Summary document with the resident's signature did not have physician treatment orders attached to it, and verified the electronic copy of the Discharge Summary did not have the resident's signature on it. Interview on 10/09/24 at 12:09 P.M. with PT #337, who worked with Resident #27, revealed Resident #27 would need a home health care agency nurse for wound care to ensure the correct procedure was done. This deficiency represents non-compliance investigated under Complaint Number OH00158232. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 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 365902 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 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 0921 Level of Harm - Potential for minimal harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview and document review, the facility failed to maintain a sanitary environment. This had the potential to effect all 26 residents residing in the facility. Residents Affected - Many Findings include: Review of the document titled State of Ohio Food Inspection Report, dated 09/20/24, revealed there was several spots on the wall in the back storage room, near the mop closet and near the stairway that had dark colored growth on the walls. It was noted the inspector was concerned the water that leaked from the ceiling or walls caused the dark colored growth in the kitchen area. An observation on 10/08/24 at 11:24 A.M. with the Maintenance Director (MD) #330 revealed a black-like substance resembling mold growth on the lower northwest wall leading into the kitchen. Additionally, the facility stored resident service wear on plastic shelves and a freezer was positioned in front of this wall. An Interview conducted on 10/08/24 at 11:26 A.M. with MD #330 confirmed the presence of a black-like substance on the wall leading to the kitchen, as well as behind the plastic shelving and a freezer. An interview with the Director of Nursing and the Administrator on 10/08/24 revealed they were aware of the results of the local county health inspection since 09/20/24 regarding the dark colored growth on the wall leading into the kitchen. This deficiency represents non-compliance investigated under Complaint Number OH00158268. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365902 If continuation sheet Page 4 of 4