Health inspection·May 16, 2022

F 0550 #57 received and was consuming her meal while Resident #21 had not still not received a meal. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 2 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to provide a comfortable wheelchair for Resident #30. This affected one resident of four reviewed for accommodation of needs. The facility census was 89. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed they were admitted to hospice care on 02/07/22. Observations throughout the afternoon on 05/09/22 found Resident #30 sitting in a geriatric (geri) chair. They were positioned properly but did not appear comfortable as evidenced by his head and shoulders were approximately one foot above the back of the chair. Resident #30 appeared to be sitting stiffly trying to support his head. His face appeared strained. The geri chair appeared to be too small for the resident. Observations throughout the morning on 05/10/22 revealed Resident #30 sitting forward in a geri chair. Their back was not against the back of the chair. Resident #30 did not appear comfortable as evidenced by restlessness and straining. Observation on 05/10/22 at 11:07 A.M. revealed Resident #30 seated in a geri chair against the back rest. The back rest ended at the resident's shoulders with no support for their head or neck. Observation on 05/11/22 at 7:42 A.M. revealed Resident #30 asleep in a geri chair with their ankles and feet over the end of the footrests. Interview on 05/11/22 at 7:45 A.M. Registered Nurse (RN) #356 verified Resident #30 did not fit comfortably in the geri chair. RN #356 stated this chair was provided by hospice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 3 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 - Some 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** 2. Review of Resident #2's medical record revealed an admission date of 08/07/18. Diagnoses included restlessness and agitation, dementia, major depressive disorder, and cerebral infarction. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #2 was severely cognitively impaired. Resident #2 was totally dependent on staff for transfer, and locomotion. Resident #2 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Review of Resident #2's care plan revised 04/28/22 revealed supports and interventions for self-care deficit, and impaired physical mobility. Resident #2 was noted to slide down nearly out of his customized specialty wheelchair. A wheelchair provider recommended the use of a seatbelt. Observation on 05/09/22 11:47 P.M. found Resident #2 seated in his customized wheelchair in the dining room for lunch. Resident #2 was found to have dried bacon and dirt and debris built up on the brakes and connecting bars of his wheelchair. Observation and attempted interview on 05/09/22 at 11:56 A.M. found Resident #2 was not able to be interviewed. Resident #2 had been provided his lunch meal and was observed feeding himself bite size pieces using his hands. Resident #2 was observed having some difficulty getting the food from his plate to his mouth and was observed dropping pieces of chicken onto his lap. Interview on 05/09/22 at 12:01 P.M. with State Tested Nursing Assistant (STNA) #380 verified Resident #2's wheelchair had dried bacon as well as built up dirt and debris on his wheelchair. STNA #380 stated resident wheelchairs were to be cleaned at the end of the day. STNA #380 verified Resident #2's wheelchair did not appear to have been cleaned. Interview on 05/09/22 at 12:08 P.M. with Dietary Staff #498 verified the dried bacon on Resident #2's wheelchair was from breakfast. Dietary Staff #498 was not able to determine what the other built up debris was and verified the wheelchair was dirty. This deficiency substantiates Master Complaint Number OH00132531. Based on observation, resident interviews, and staff interviews, the facility failed to ensure resident rooms and wheelchairs were kept in a clean and sanitary manner. This affected eight residents (#2, #32, #39, #50, #52, #56, #60, and #87) out of eight residents reviewed for environmental concerns. The facility census was 89. Findings include: 1. Observation on 05/10/22 at 8:20 A.M. revealed Resident #39's room smelled of urine. Resident #39 was not in the room at the time. Interview on 05/10/22 at 8:20 A.M. with Medication Aide #513 confirmed Resident #39's room smelled of urine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 4 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 - Some Observation of Resident #50's room on 05/10/22 from 11:15 A.M. to 11:21 A.M. revealed an unmade bed, dirty linen on the sink and dirty clothing in a pile on the floor in the left hand corner of the room. There was dark, sticky debris on the floor in four of four corners of the room and on the metal threshold between the room and the hallway and the dark, sticky debris rubbed off when scuffed with the Surveyor's shoe. There was also a sticky substance on the floor in front of sink which caused the Surveyor's shoes to stick to the floor. Observation of Resident #87's room on 05/10/22 at 11:27 A.M. revealed dark discoloration to four of four corners in the room along with a dark sticky substance built up on the metal threshold between the hallway and room. The dark sticky substance on the metal threshold scuffed off with the Surveyor's shoe. Observation of Resident #52's room on 05/10/22 at 11:34 A.M. revealed a tile floor with a change in color from light to dark from the bathroom to the room and had multiple scuff marks. The line of change was uneven and sticky when walked on. There was a maroon colored reclining chair in the corner of room with white substance on the cushion of chair. There was an opened wound dressing package, four inches by four- and three-quarter inches sitting on the right side of the sink with a notation on the package which indicated the dressing was sterile. Interview with Licensed Practical Nurse #439 (LPN) on 05/10/22 at 11:40 A.M. stated the Resident #52 had been transferred to the hospital two days ago. Interview with Housekeeper #413 at 05/10/22 at 11:52 A.M. verified Resident #52's room had not been cleaned since the resident discharged two days ago. Housekeeper #413 further added rooms were to be cleaned daily. Housekeeper #413 stated she was unable to complete her work each shift. Housekeeper #413 stated she was required to clean staff areas, the break room and then nurses stations prior to resident rooms, further, Housekeeper #413 admitted she does not get to all resident rooms every day. Observation of Housekeeper #413 cleaning cart on 05/10/22 at 11:52 revealed a full unlabeled spray bottle with purple liquid. Interview with Housekeeper #413 at the time of the observation verified the spray bottle containing the purple liquid was unlabeled. Housekeeper #413 was unable to provide the name of liquid in the spray bottle. Observation on 05/10/22 at 11:53 A.M. of Resident #32 and Resident #56's room revealed scuff marks on the tile floor and a dirty, used glove on the floor next to an empty trash can. Observation on 05/10/22 at 12:21 P.M. of Resident #60's room revealed a tile floor with dark colored build up in four of four corners of room and on the floor around the wood vanity. The transition from the carpeted hallway with a metal transition strip contained dark debris which rubbed off with the Surveyor's shoe. There was also additional dark sticky areas on the tile floor next to the bed with scuff marks on the floor throughout the room. Interview on 05/12/22 at 11:23 A.M. Resident #60 stated the housekeeping staff do not sweep or mop her bedroom floor often enough and stated her room was not as clean as she would like it. Interview on 05/12/22 at 3:15 P.M. Housekeeping Supervisor #400 verified the discoloration, debris and scuff marks on the floors of Resident (#32, #50 #52, #56, #60 and #87) rooms. Housekeeping (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 5 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 Supervisor #400 further added he received complaints about the condition of the floors in the Vineyard Unit from both residents and resident's family members. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 6 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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, staff interview, family interview, and review of facility policy, the facility failed to provide a copy of the baseline care plan to Resident #46 or Resident #46's family. This affected one resident (#46) out of seven residents reviewed for care planning. The facility census was 89. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including muscle weakness, macular degeneration, dementia, anxiety, heart disease and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. Resident #46 required extensive assistance of two people for bed mobility, toilet use and transfers. Review of the baseline care plan for Resident #46 revealed the baseline care plan was developed on 01/19/22, however was the baseline care plan had not been not signed or dated by Resident #46 or by Resident #46's family. Interview on 05/12/22 at 2:35 P.M. the Director of Nursing (DON) verified baseline care plans were to be developed and signed and dated when shared with the resident and or the resident's family. At the time of the interview, the DON verified a copy of the care plan was not provided to Resident #46 or her family. Interview on 05/11/22 at 3:05 P.M. Resident #46's family reported no baseline care plan was shared or received from the facility upon Resident #46's admission in January 2022. Review of the facility's undated policy titled, Care Plan Policy, revealed the facility was to develop and implement a comprehensive person centered care plan for each resident that included measurable objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 7 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to review and revise a resident's care plan. This affected one resident (#30) out of seven residents reviewed for care plannning. The census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed admission to hospice care on 02/07/22. Further review of the medical record revelaed Resident #30 had falls on 05/01/22 and 05/03/22. Review of progress notes revealed both falls happened when the resident attempted to stand up from a geriatric (geri) chair. No major injuries were noted for either fall. Review of the care plan for Resident #30 revealed an update on 03/11/22 recommending a geri chair for comfort if the resident was restless in other chairs as an intervention for falls. No additional fall interventions were added to the care plan after 03/11/22, verifying the care plan had not been updated with additional fall interventions after Resident #30 suffered falls on 05/01/22 and 05/03/22. Interview on 05/11/22 at 1:35 P.M. the Director of Nursing (DON) stated a new intervention of assiting Resident #30 to the restroom was initiated after Resident #30's fall on 05/01/22. The DON verified no additional interventions to prevent future falls were added to the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 8 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with shaving and fingernail care. This affected one resident (#83) of four residents reviewed for activities of daily living. The facility census was 89. Residents Affected - Few Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included history of COVID-19, dementia, and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #83 displayed no behaviors during the review period. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care and getting up unassisted, risk for mood problems, resident preferences for personal care, and self-care deficit. Supports for self-care deficit included to provide assistance with activities of daily living. Staff were to check nail length, trim, and clean Resident #83's nails on bath day and as necessary. Resident #83 was totally dependent on staff to provide a bath or shower. Resident #83 required extensive assistance of one to two staff to maximize independence with personal hygiene. Observation on 05/09/22 at 10:09 A.M. of Resident #83 found him lying in bed. Resident #83's fingernails were long with a yellowish brown substance under them. Resident #83 had facial hair growth of approximately a centimeter long. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found he was alert and orientated. Resident #83 reported he needed assistance with shaving and trimming his nails. Resident #83 stated he had told staff he wanted to be shaved and have his nails trimmed, but no one who would do it for him. Observation on 05/10/22 at 8:06 A.M. of Resident #83 found him up in his wheelchair. Resident #83's fingernails continued to untrimmed and dirty. Resident #83 continued to have facial hair. Interview on 05/10/22 at 8:10 A.M. with State Tested Nursing Assistant (STNA) #328 verified Resident #83 had not been shaven and his nails were not trimmed. STNA #328 stated Resident #83 was to have his nails trimmed and his facial hair shaved with his weekly shower and as needed or requested. Review of the facility policy titled, Grooming a Resident's Facial Hair, dated 2022 revealed it was the facility's practice to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Review of the facility policy titled, Fingernail Care, dated July 2001 revealed residents would be given proper nail care by staff to ensure the nails were kept clean, trimmed, and healthy. This deficiency substantiates Complaint Number OH00132162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 9 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 record review and staff interview, the facility failed to provide wound treatments as ordered. This affected one resident (#67) out of five residents reviewed for wound care. The facility census was 89. Residents Affected - Few Findings include: Review of the medical record for Resident #67 revealed an admission date of 11/09/09 with medical diagnoses of abnormal posture and anxiety disorder, and non-pressure chronic ulcer of right ankle with unspecified severity. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #67 had intact cognition and required extensive assistance of two people for bed mobility, dressing, toilet use, personal hygiene, and required total dependence of two people for transfers. Resident #67 used a wheelchair for mobility. Review of Resident #67's orders revealed daily treatment orders for his right outer ankle wound from 12/12/21 through 05/11/22. Review of Resident #67's Treatment Administration Record (TAR) for February 2022 revealed four treatments for his right outer ankle were not documented in the record on 02/12/22, 02/17/22, 02/21/22, and 02/25/22. Review of Resident #67's TAR for March 2022 revealed four treatments for his right outer ankle were not documented in the record on 03/13/22, 03/14/22, 03/26/22, and 03/27/22. Review of Resident #67's TAR for April 2022 revealed four treatments for his right outer ankle were not documented in the record on 04/08/22, 04/12/22, 04/15/22, and 04/23/22. Interview on 05/12/22 at 1:45 P.M. the Director of Nursing (DON) confirmed Resident #67's TARs for February, March, and April 2022 were missing documentation of wound treatments to his right outer ankle for four days each month. Review of the wound care consult notes for Resident #67 dated 05/04/22 revealed the wound was vascular, and was improved and healing. This deficiency substantiates Master Complaint Number OH00132531 and Complaint Number OH00132162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 10 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview the facility failed to ensure residents received timely care and treatment for vision and audiology. This affected one resident (#83) out of one resident reviewed for ancillary services. The facility census was 89. Residents Affected - Few Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 had adequate vision and hearing at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative consented to vision services, dental services, podiatry services, and audiology services to be arranged by the facility. Further review of Resident #83's medical record found no evidence Resident #83 was seen by the audiologist or optometrist since admission on [DATE]. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found Resident #83 was alert and aware. Resident #83 reported he had not seen an eye doctor or anyone for his hearing for a very long time. Resident #83 stated he would like to be checked out. Interview on 05/11/22 at 9:48 A.M. the Administrator #496 verified Resident #83 had not had any ancillary services appointments for hearing or vision. Administrator #496 provided evidence of upcoming scheduled appointments. Review of Resident #83's scheduled appointments revealed Resident #83 was scheduled on 05/25/22 for an audiology appointment, and on 06/22/22 for a vision appointment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 11 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to implement ordered treatments to potentially prevent pressure ulcers. This affected one resident (#30) of four residents reviewed for pressure ulcers. The census was 89. Residents Affected - Few Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed Resident #30 admitted to hospice care on 02/07/22. Review of physician orders for Resident #30 revealed an order to, keep elbow protectors in place at all times, dated 01/28/22. It also revealed an order for, bilateral heel lift boots at all times, dated 01/27/22. Observation of Resident #30 throughout the afternoon on 05/09/22 found the resident sitting up in a geriatric (geri) chair in the common area next to the nurse's station. Resident #30 did not have heel protectors or elbow protectors in place. There were no visible wounds observed. Observation of Resident #30 throughout the morning on 05/10/22 found the resident sitting in a geri chair by the nurses station. Resident #30 did not have heel protectors or elbow protectors in place and no visible wounds. Interview on 05/10/22 at 1:45 P.M. State Tested Nurse Aide (STNA) #338 verified Resident #30 had orders for heel protectors and elbow protectors. STNA #338 stated Resident #30 refused to wear the heel and elbow protectors. STNA #338 was unaware of the last time staff attempted to put heel protectors or elbow protectors on the resident. Observation of Resident #30's room on 05/10/22 at 1:49 P.M. found his heel protector boots were kept in a chair in his room. Resident #30 had no elbow protectors available for use. Observation of Resident #30 on 05/11/22 throughout the morning revealed the resident sitting in a geri chair in the main living area with heel protectors and elbow protectors on. Resident #30 appeared calm and was not attempting to remove the treatments. Further review of Resident #30's medical record revealed no pressure areas or skin concerns in the past 30 days. This deficiency substantiates Master Complaint Number OH00132531 and Complaint Number OH00132162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 12 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide range of motion as ordered. This affected one resident (#7) of four residents reviewed for positioning and range of motion. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included adjustment disorder, Alzheimer's disease, and wedge compression fracture of first lumbar vertebra (at admission). Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one indicating Resident #7 was severely cognitively impaired. Resident #7 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #7 was totally dependent on staff for eating. Resident #7 was receiving therapy services at the time of the review. Resident #7 had delusions during the review period and displayed physical and verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #7's care plan revised 04/08/22 revealed supports and interventions for risk for falls, verbal and physical behaviors, and impaired cognitive function. Review of Resident #7's therapy orders revealed an order dated 03/29/22 for Restorative Nursing to start on 03/30/22. Resident #7 was to get right lower extremity and left lower extremity range of motion. It was noted Resident #7 required extensive verbal, tactile, and visual cues to participate. Resident #7's range of motion (ROM) exercises included a seated march, seated long arc quad, seated ankle dorsiflexion active range of motion, seated heel raise, and seated hip abduction. Review of Resident #7's State Tested Nursing Assistant (STNA) Tasks for the last 30 days revealed Resident #7 was provided range of motion (ROM) six times. ROM was provided on 04/17/22, 04/19/22, 04/28/22, 05/01/22, 05/02/22 and 05/07/22. Resident #7 was documented as refused ROM 11 times, on 04/12/22, 04/15/22, 04/18/22, 04/24/22, 04/26/22, 04/29/22, 04/30/22, 05/03/22, 05/04/22, 05/08/22 and 05/10/22. Resident #7 was not offered ROM services 13 times on 04/11/22, 04/13/22, 04/14/22, 04/16/22, 04/20/22, 04/21/22, 04/22/22, 04/23/22, 04/25/22, 04/27/22, 05/05/22, 05/06/22, and 05/09/22. Interview on 05/09/22 at 9:31 A.M. with Resident #7's wife revealed Resident #7 was no longer receiving therapy services because he was not cooperative. Resident #7's wife reported Resident #7 was to be receiving ROM services from the STNAs daily and they were not doing anything with him. She said they maybe did ROM a handful of times since he had been on the secured unit. Interview on 05/09/22 at 11:08 A.M. with State Tested Nursing Assistant (STNA) #447 verified Resident #7's ROM was to be completed daily as indicated in Resident #7's therapy order. STNA #447 stated Resident #7 was often noncompliant with care. STNA #447 reported all refusals and minutes of ROM completed were documented in the electronic medical record under tasks. Review of Resident #7's ROM tracking with STNA #447 verified there were 13 times in the last 30 days Resident #7 was not provided ROM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 13 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0688 Level of Harm - Minimal harm or potential for actual harm Review of the undated facility policy titled, Range of Motion, revealed a range of motion program was to be developed based on the residents unique risk factors. Nursing's primary responsibility was to preserve the resident's range of motion. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 14 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in actual harm when a resident experience repeated falls, with one resulting in a fracture requiring surgery. This affected one resident (#46) out of four residents reviewed for falls. The census was 89. Finding include: Review of the medical record for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, macular degeneration, dementia, anxiety, heart disease and major depressive disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility, toilet use and transfers. The assessment revealed Resident #46 had no history of falls prior to admission. Review of the Care Area Assessment (CAA) worksheet revealed falls and functional status would be addressed in the care plan to avoid complications and minimize risks. Review of a fall risk assessment dated [DATE], revealed Resident #46 was at high risk for falls. Review of the baseline care plan dated 01/19/22, revealed the care plan did not address Resident #46's risk for falls and did not include interventions to potentially prevent falls. Review of the comprehensive care plan dated 01/31/22, revealed the care plan did not address Resident #46's risk for falls and did not include interventions to potentially prevent falls. Further review of the of the admission MDS assessment dated [DATE] revealed Resident #46 triggered the CAA Summary for falls. Review of the CAA Fall Summary, completed on 02/04/22, revealed falls would be addressed in the care plan to avoid complications and to minimize risk due to injury associated with falls related to weakness, mobility, transfer, and balance impairment along with vision impairment, frequent incontinence, decreased safety awareness and severe cognitive impairment. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. The resident required extensive assistance of two people for bed mobility, toilet use and transfers. Review of the updated comprehensive care plan dated 03/17/22 revealed the care plan continued to lack evidence of any documentation for Resident #46's risk for falls and did not include interventions to potentially prevent falls. Review of a document titled, Summary Fall Event, dated 03/23/22 at 3:50 P.M., revealed Resident #46 was found sitting on the bathroom floor with her pants at her ankles. The resident reported she was taking herself to the bathroom. Mild injury noted, skin tear to left buttock which required first aide. Resident #46 was re-educated to use of the call light and the importance of staff assistance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 15 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of a document titled, Incident Audit Report, dated 04/14/22 at 3:45 P.M., revealed Resident #46 was heard yelling for help and was found sitting on buttocks on the bathroom floor with her wheelchair beside her. Resident #46 complained of right hip pain. Staff noted right leg to be shorter. Documentation revealed the resident was trying to go to the bathroom. Resident #46 was assessed and due to pain and crying, emergency services were called. Resident #46 was sent to the hospital for evaluation and treatment. Resident #46 was found to have a right femoral neck fracture requiring a right hip replacement. Review of Good [NAME] Home communication dated 04/14/22 sent to the facility nurses and nursing assistants revealed Resident #46 was not to be left in her wheelchair unattended in her room or left in the bathroom on the toilet unattended. Review of Resident #46's hospital medical record revealed the resident sustained a closed, displaced right femoral neck fracture that required a right hip hemiarthroplasty (hip replacement) on 04/16/22. Review of the updated comprehensive care plan dated 04/27/22, again revealed the care plan lacked documentation for Resident #46's risk for falls and did not include interventions to potentially prevent falls. Further review of the comprehensive care plan revealed a fall care plan with interventions was not developed until 05/02/22. The resident returned to the facility from her surgery on 04/19/22. Interview on 05/12/22 at 2:35 P.M. with the Director of Nursing (DON) verified Resident #46 was identified upon admission as a high fall risk resident and was at risk for injury related to falls. The DON further validated the comprehensive care plan for Resident #46 was absent of fall interventions until interventions were initiated on 05/02/22. The DON verified Resident #46 had a fall resulting in a fracture, which required surgery. Review of the facility policy titled, Fall Policy, indicated when a resident is identified at risk for falls the facility is to implement a fall prevention program to reduce the risk of falls and serious injury related to falls and to incorporate the fall risk prevention in the resident's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 16 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #39 revealed an admission date of 07/02/19 and medical diagnoses of type II diabetes mellitus and paranoid schizophrenia. Residents Affected - Few Review of the quarterly MDS dated [DATE] revealed Resident #39 had intact cognition and required extensive assistance of one person for transfers, dressing, toileting, and hygiene, and required only supervision with setup for eating. Review of an order dated 09/23/21 revealed Resident #39 received a regular diet with low fiber, regular textures and thin liquids. Review of Resident #39's current care plan revealed he had a nutritional problem or potential nutritional problem. Interventions included monitoring, recording, and reporting to the physician as needed any signs or symptoms of malnutrition, including weight loss greater than 7.5% in three months and greater than 10% in six months, discourage sweets/donuts, and limit to one entree per meal. Review of the meal intakes for Resident #39 from 04/15/22 to current revealed he consumed 95-100% of his meals. Review of Resident #39's weights over the past six months revealed an 8.7% weight loss over the last three months and a 15% weight loss over the last six months. His weight on 05/09/22 was 199.0 pounds and his body mass index (BMI) was 28.6. Review of a nutrition progress note dated 03/08/22 revealed Resident #39 had significant weight loss from the previous six months, was eating well, and was well above his weight from three years prior. The dietitian did not make any recommendations to offset the weight loss. Review of a nutrition progress note dated 05/09/22 revealed Resident #39 had a significant weight loss over the past six months, though meal intake was good. The dietitian indicated a supplement may be considered in the future to offset the weight loss, and further noted Resident #39's weight was higher than his weight in 2019. Observation on 05/09/22 at 11:48 A.M. revealed Resident #39 consumed 100% of his noon meal. Interview on 05/10/22 at 7:57 A.M. with Resident #39 revealed he thought he had lost weight because he just did not feel like eating. Interview on 05/11/22 at 3:07 P.M. with the RD #514 confirmed Resident #39 had significant weight loss over the past six months beginning in March 2022. The RD #514 further confirmed Resident #39 did not receive nutrition supplements, and was not on an ordered weight loss program. RD #514 revealed he did not meet with facility staff to discuss weight changes and would notify the physician of significant weight changes through his documentation in the medical record. Further interview revealed RD #514 did not feel a supplement would be nutritionally valuable to Resident #39, though he did want Resident #39's weight to stabilize. Continued interview with RD #514 revealed he did not speak with Resident #39 regarding his most recent weight loss. Interview on 05/12/22 at 3:22 P.M. with the Director of Nursing (DON) revealed nursing staff was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 17 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 - Minimal harm or potential for actual harm Residents Affected - Few responsible for notifying the physician of significant weight changes. Further interview revealed the facility relied on the dietitian to recommend interventions when residents had significant weight changes. Review of facility policy titled, Dietary Weight Monitoring Program, revised 01/2018, stated in the event of significant or patterned weight loss, The dietician will assess the resident, document the assessment, and make recommendations in the resident's medical record. Orders may be obtained for nutritional supplements or other interventions. Based on medical record review, staff interview, and review of facility policy, the facility failed to address the nutritional needs of residents with significant weight loss. This affected two residents (#30 and #39) of five residents reviewed for significant weight loss. The census was 89. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed the resident was admitted to hospice care on 02/07/22. Review of Resident #30's weights revealed a weight of 185 pounds on 12/22/21 and 157 pounds on 05/04/22, indicating a significant (15%) weight loss over five months. Resident #30 weighed 173 pounds on 02/09/22 indicating a 12-pound weight loss prior to hospice admission. Review of a progress note dated 02/19/22 written by Registered Dietitian (RD) #514 revealed Resident #30 weighed 171 pounds and had significant weight loss. The progress note also revealed intake of oral fluids was less than optimal. No interventions were noted in the progress notes at that time. Review of a progress note dated 05/09/22 written by RD #514 revealed Resident #30 weighed 157 pounds and had significant weight loss. The progress note also said, Could consider use of supplement if it would provide comfort overall. No interventions were recommended in the note. Interview with RD #514 on 05/11/22 at 3:10 P.M. revealed RD #514 did not recommend aggressive interventions for residents receiving hospice care. RD #514 also verified Resident #30 lost 12 pounds prior to being admitted to hospice care and stated their nutrition intervention was hospice. Interview with RD #514 on 05/12/22 at 9:00 A.M. stated RD #514 did not communicate which residents had significant weight loss with the interdisciplinary team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 18 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure pharmacy recommendations were timely addressed by the physician. This affected one resident (#7) of five residents reviewed for unnecessary medications. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included type II diabetes, adjustment disorder, dementia, major depressive disorder, and Alzheimer's disease. Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one, indicating Resident #7 was severely cognitively impaired. Resident #7 had delusions during the review period and displayed physical and verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #7's care plan revised 04/08/22 revealed supports and interventions for risk for falls, chronic pain, verbal and physical behaviors, impaired cognitive function, use of psychotropic medications, antidepressant use, and risk for drug related complications. Review of Resident #7's physician orders revealed an order dated 02/02/22 with a discontinuation date of 05/03/22 for Quetiapine Fumarate (antipsychotic) 25 milligrams (mg) give one tablet at bedtime related to dementia without behavioral disturbance. An order dated 05/03/22 for Seroquel 25 mg at bedtime for psychosis. Review of Resident #7's monthly pharmacy reviews revealed Resident #7's medications were reviewed on 02/04/22, 03/18/22, and 04/16/22. Review of Resident #7's pharmacy recommendations revealed on 02/04/22 the pharmacist reviewed Resident #7's Quetiapine and recommended an active diagnosis be added to the electronic medical record to support the therapy. It was noted an antipsychotic should only be uses for schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, schizophreniform disorder, psychosis not otherwise specified, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms, medical illnesses or delirium with manic or psychotic symptoms. The physician checked the disagree box on the pharmacist recommendation form on 03/01/22 and noted I will evaluate. No diagnoses was added to Resident #7's electronic medical record. Review of Resident #7's Mental Health New Patient Progress Note dated 04/07/22 revealed Resident #7's medications were reviewed by the Physician Assistant and a diagnosis of unspecified psychosis was added. The plan was to monitor for psychosis and continue Seroquel at the same dose. Resident #7's physician orders and Medication Administration Record (MAR) were not updated with the new diagnosis in the electronic medical record. Interview on 05/12/22 at 1:30 P.M. with the Director of Nursing (DON) verified Resident #30's electronic medical record was updated on 05/03/22 with the diagnosis of psychosis. The DON reported she thought Resident #7 was also seen by a mental health provider and his mental health provider added (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 19 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0756 the diagnoses at an earlier date. Level of Harm - Minimal harm or potential for actual harm Interview on 05/12/22 at 3:23 P.M. with the DON found Resident #7's mental health provider reviewed Resident #7's medications on 04/07/22 and added the diagnosis of unspecified psychosis. The diagnoses was added two months after the pharmacy recommendation and was not added into Resident #7's electronic medical record as requested by the pharmacist. Residents Affected - Few Review of the facility policy titled, Documentation and Communication of Consult Pharmacist Recommendations and Pharmacy Services, dated 07/01/12 revealed recommendations were to be acted upon and documented by the facility and/or the prescriber within 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 20 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview the facility failed to ensure residents received timely dental services. This affected one resident (#83) of one resident reviewed for ancillary services. The facility census was 89. Residents Affected - Few Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating Resident #83 was moderately cognitively impaired. Resident #83 had no oral concerns at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative consented to vision services, dental services, podiatry services, and audiology services to be arranged by the facility. Further review of Resident #83's medical record found no evidence Resident #83 was seen by a dentist since admission on [DATE]. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found Resident #83 was alert and aware. Resident #83 reported he had not seen a dentist for a very long time. Resident #83 stated he would like to be checked out. Interview on 05/11/22 at 9:48 A.M. with Administrator #496 verified Resident #83 had not had any ancillary services appointments for dental care. Review of Resident #83's scheduled appointments revealed Resident #83 was not scheduled for a dental appointment due to him being private pay. No evidence was found of the facility attempting to assist with arrangements for dental services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 21 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly, staff prepared food in a sanitary manner, and failed to ensure the dishmachine reached appropriate temperatures. This had the potential to affect 88 residents in the facility. The facility identified one resident (#32) did not receive oral nutrition. The facility census was 89. Findings include: 1. Observations on 05/09/22 beginning at 8:33 A.M. revealed an open bag of chicken, an open box of hashbrowns, and individual flatbread lying loose on the shelf in the walk-in freezer, and one large can of mandarin oranges and one large can of raspberry filling dented near the seal stored with the in-use canned food items. Interview on 05/09/22 at 8:46 A.M. with the Culinary Director #507 confirmed the chicken, hashbrowns and flatbread were stored inappropriately, and the dented cans should be removed from use. Observation and interview on 05/09/22 at 8:52 A.M. with the Culinary Director #507 revealed two opened, undated bags of hardboiled eggs with cloudy fluid inside, leaked when they were picked up, and were inappropriately stored in an additional walk-in refrigerator. Observation and interview on 05/09/22 at 8:58 A.M. with the Culinary Manager #507 confirmed deli ham dated 05/01/22 was in the refrigerator of the kitchen on the locked unit. The Culinary Manager #507 confirmed the ham was beyond the date of use. Observation and interview on 05/09/22 at 9:03 A.M. with the Culinary Manager #507 confirmed personal food and expired chocolate milk were in the stand-up refrigerator on the 200-hall. The Culinary Manager #507 further confirmed the coleslaw located in the low reach-in refrigerator on the 200-hall was expired. Review of the facility policy titled, Date Marking for Food Safety, dated 03/28/22, revealed food items should be marked to indicate the date by which the food shall be consumed or discarded, and refrigerated food items should be held for a maximum of seven days. 2. Observation on 05/09/22 at approximately 8:56 A.M. revealed Dietary Assistant #388 wearing disposable gloves and used a handle to open a compartment, removed a clean plate, closed the compartment, put a toasted sandwich on the plate, opened another compartment, removed bacon slices with her gloved hands, and placed the bacon on the plate. Interview on 05/09/22 at approximately 8:57 A.M. with the Dietary Assistant #388 confirmed she did not change gloves between touching handles and touching consumable food. Further interview revealed the sandwich and bacon was for Resident #88. Interview on 05/09/22 at approximately 8:57 A.M. with the Culinary Director #507 confirmed the Dietary Assistant #388 did not practice appropriate hand sanitation while plating the sandwich. Observation on 05/09/22 at 8:48 A.M. revealed the sandwich and bacon was delivered to Resident #88. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 22 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. Observation on 05/11/22 at 1:35 P.M. of the dishmachine revealed the wash temperature ranged from 100 degrees fahrenheit to 105 degrees fahrenheit. Further observation of the dishmachine revealed posted guidelines for washing temperatures to be at least 120 degrees fahrenheit. Interview on 05/11/22 at 1:55 P.M. revealed Dietary Assistant #365 was running the dishmachine, but did not know who was required to complete the dishmachine temperature log. Interview on 05/11/22 at 1:53 P.M. with the Chef Manager #475 confirmed the washing temperature of the dishmachine ranged between 100 to 105 degrees fahrenheit. Interview and observation of the dishmachine on 05/12/22 at 12:35 P.M. with the Culinary Director #507 revealed the wash temperature was 93 degrees fahrenheit. Further interview revealed the dishmachine was a chemical sanitizer and a high temperature machine. Continued interview revealed most of the kitchen staff was new and had not been trained on monitoring and completing the logs for the dishmachine. Review of the facility policy titled, Good [NAME] Home Dishwasher Temperature, dated 2021, revealed the wash temperature should be 120 degrees fahrenheit for a chemical sanitizing machine, and should be 150-165 degrees fahrenheit for a high temperature machine. Review of the Infection Control logs from October 2021 to current revealed no foodborne illness had occurred at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 23 of 24 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 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 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 Based on observation, staff interview, review of manufacturer's instructions, and review of facility policy, the facility failed to ensure staff properly cleaned and disinfected the blood glucometer per manufacturer's recommendations. This had the potential to affect eight residents (#8, #23, #28, #31, #39, #41, #74 and #75) receiving blood sugar checks in the Meadows Unit. Facility census was 89. Residents Affected - Some Findings include: Observation on 05/10/22 at 7:36 A.M. revealed Licensed Practical Nurse (LPN) #376 administering medications on the Meadows Unit and cleaned the blood glucometer with two alcohol wipes. Interview with LPN #376 at the time of the observation on 05/10/22 at 7:36 A.M. verified blood glucometer's are cleaned with alcohol. Interview with LPN #376 on 05/10/22 at 2:30 P.M. verified LPN #376 used alcohol to clean the blood glucometer before and after the morning blood sugar check for Resident #74, with LPN #376 further stating she should have used a disinfectant wipe. Review of facility policy titled, Glucometer Disinfection, with a review date of 02/21 verified blood glucometer should be cleaned and disinfected after each use and according to manufacturer instructions. Review of the undated manufacturer's instructions for blood glucometer used revealed any disinfectant product with the Environmental Protection Agency (EPA) number 67619-12 was to be used on the device for cleaning and disinfection. This deficiency substantiated Complaint Number OH00132162. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 24 of 24