Health inspection·January 10, 2019

F 0623 the discharges. Level of Harm - Minimal harm or potential for actual harm Interview with Licensed Social Worker (LSW) #200 on 01/10/19 at 1:20 P.M. verified the facility failed to notify the local Ombudsman of the discharge of Resident #126 on 11/02/18. Residents Affected - Few Interview with LSW #200 and the Director of Nursing on 01/10/19 at 1:28 P.M. verified that the facility failed to send a notice of transfer/discharge to the family of Resident #11 on 09/04/18 and 11/07/18. Review of the facility policy titled Transfer/Discharge Notice Procedure undated, revealed the resident, responsible party and/or the resident representative would be given a Transfer/Discharge Notice at the time of discharge, or as soon as practical thereafter. This notice would include the ombudsman contact information and rights to appeal such transfer or discharge. All unplanned or facility-initiated discharges would be added to the tracker for monthly submission to the Ombudsman's office. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 2 of 5 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 366072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows at Osborn Park 3916 Perkins Ave Huron, OH 44839 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 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed to accurately reflect the residents status. This affected one (#2) of two (#2 and #1) resident MDS assessments reviewed. The facility census was 125. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 02/22/18. Diagnoses included lung cancer, urinary tract infection, and atrial fibrillation. Further review revealed the resident discharged from the facility on 09/19/18. Review of Resident #1's MDS assessments revealed a discharge assessment was not completed for the resident. Interview on 01/10/19 at 9:04 A.M., Registered Nurse (RN) #333 confirmed Resident #1 should have had a discharge assessment dated [DATE] completed and did not. Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, chapter two, page two-34, dated 10/2014, revealed a discharge MDS assessment must be completed for all resident who discharged from a facility. The discharge assessment should of reflected weather the resident was expected to return to the facility or not. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 3 of 5 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 366072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows at Osborn Park 3916 Perkins Ave Huron, OH 44839 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 0660 Plan the resident's discharge to meet the resident's goals and needs. 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, facility policy and staff interviews, the facility failed to ensure residents had a plan in place for discharge to the least restrictive environment. This affected one (Resident #31) of three residents reviewed for discharge. The facility census was 125. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis including Bipolar disorder. Review of progress notes dated 04/25/18 at 1:36 P.M., identified guardian told Resident #31 they would look at discharge after so many months of working. Review of a Care Conference Meeting Documentation dated 04/19/18 identified no evidence of anyone reviewing Resident #31's wishes for discharge plans being made. Review of progress notes dated 07/24/18 at 8:50 A.M. identified Resident #31 struggles with nursing home placement; no plan for discharge presently guardian does not want to be asked about it. The medical record identified no written plan of care for Resident #31's desire to discharge from the facility to a less restrictive environment. Review of the Minimum Data sets (MDS/Comprehensive assessments) dated 10/11/18, 07/12/18 and 04/12/18 identified she was completely independent with all activities of daily living (bed mobility, transfers, ambulation, dressing, eating, toileting and person hygiene and bathing). Interview with Resident #31 occurred on 01/07/19 at 2:37 P.M. Resident #31 identified she was completely independent with all ADL's (Activities of Daily Living) and did have a mental illness. Resident #31 identified she desired to live in a less restrictive environment and had been asking to for quite some time. Resident #31 identified she desired to discharge from the facility into a community type setting. Resident #31 confirmed she has been given a court appointed Guardian, but that person was no longer involved in her care and did not come to the facility any longer. Resident #31 confirmed she had made huge strides while in the facility and deserved a chance to live in a less restrictive environment. Interview with the Director of Nursing (DON) on 01/08/19 at 1:10 P.M., confirmed there was no current discharge plan of care established for Resident #31, although they were aware she desired to discharge to a less restrictive environment . The interview identified Resident #31 currently had a court appointed guardian and was in the process of obtaining a different one. The interview confirmed Resident #31 guardian had not been in to see Resident #31 since April 2018. The interview confirmed Resident #31 had not had any in patient psychiatry hospitalizations since September 2016 and the resident does not require assistance with any ADL's and was only receiving medication administration and counseling at the facility at the time. Review of the facility discharge planning policy, (dated September 2015) identified the social services department was to initiate discharge planning upon admission, review quarterly and contact agencies of the Residents choice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 4 of 5 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 366072 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Meadows at Osborn Park 3916 Perkins Ave Huron, OH 44839 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 Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a discharge summary was completed and post discharge plan of care for one resident (Resident #126) of three sampled for discharge. The facility census was 125. Findings include: Record review revealed Resident #126 was admitted to the facility on [DATE]. Documented diagnoses listed for Resident #125 included pulmonary embolism, muscle weakness, unspecified lack of coordination, localized edema, acute post-hemorrhagic anemia, essential tremor, hypertensive heart disease, embolism and thrombosis of superficial veins of lower extremities, peptic ulcer, and malignant neoplasm of pancreas. Record review of skilled nursing revealed Resident #126 to be alert and oriented to person, place, time and situation. Resident #126 was under palliative care, had weakness noted for activities of daily living, and required assistance from staff for bed mobility, transfers, and toilet use. Review of discharge planning review form completed on 09/12/18 revealed discharge plan upon admission to facility to be unknown. Social Worker (SW) #200 noted 'Not sure of discharge plan. Current plan was to work with therapy to gain strength and go from there, will assist with plan. Further review revealed no updated discharge plan or summary to be in place. Record review of progress notes revealed Resident #126 was discharged to an assisted living on 10/28/18. Record review revealed no plan of care in place for discharge for Resident #126. Interview on 1/10/19 at 10:56 A.M. with Director of Nursing (DON) revealed the physician order report was used by nursing staff for discharge instructions upon discharge from the facility and signed by the resident/representative. DON verified Social Services did not complete a capitulation of discharge summary or plan of care regarding discharge. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 5 of 5