Health inspection·February 6, 2020

F 0558 floor and not in the resident's reach. Level of Harm - Minimal harm or potential for actual harm 3. Review of medical record for the Resident #65 revealed an admission date of 03/06/19. Diagnoses included schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder. Residents Affected - Few Review of the annual MDS assessment, dated 12/19/19, revealed Resident #65 was severely cognitively impaired and dependent on staff for all activities of daily living. Observation on 02/04/20 at 11:35 A.M. revealed Resident #65 was reclined in her wheelchair. Her spouse was sitting on the bed. The resident's call light was looped around the call light box hung on the wall. Interview on 02/04/20 at 11:39 A.M. with the Maintenance Director (MD) #72 confirmed the call light was hung on the wall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 2 of 8 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 02/06/2020 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on observations, medical records review, resident interview, and staff interview, the facility failed to honor resident choice on roommates and who to eat meals with for two (#62 and #85) of 24 sampled residents. The facility census was 119. Findings include: Review of Resident #62's medical records identified admission to the facility occurred on 11/19/19. Medical diagnoses included dysphasia, anemia, and schizo-affective disorder. The record identified prior to admission to the facility Resident #62 lived with her sister (Resident #85) in the community. Interview on 02/03/20 at 9:28 A.M., Resident #62 identified her sister, Resident #85, was admitted to the facility in December and she wanted to be roommates with her. Resident #62 identified the facility has not made any efforts to try to accommodate the residents' wishes to room together. Resident #62 also stated when her sister and her go to the dinning room they were not permitted to sit next to one another because she required staff to fed her meals. Resident #62 confirmed she would like to sit next to her sister while they eat meals. Interview on 02/04/20 at 1:24 P.M., Resident #85 identified she was admitted in December 2019 and was not offered to live in the same room with her sister (Resident #62). Resident #85 identified she lived with Resident #62 prior to admission and really would like to be in the same room with her now. Observation of the breakfast meal on 02/05/20 at 8:14 A.M. identified Resident #62 was placed at the table with other resident's who need staff to feed them their meal. Resident #85, who was capable to feeding herself, was placed at a different table. Interview on 02/05/20 at 9:11 A.M., facility Social Worker #87 identified Resident #62 and Resident #85 were separated as the facility thought this was the best for them. Social Worker #87 confirmed Resident #62 and Resident #85 were not provided the right to room together and or choices regarding where they sit in the dinning room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 3 of 8 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 02/06/2020 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, family interview, review of financial records, and staff interview, the facility failed provide the notice of bedhold policy upon discharge to the hospital for one (#166) of three residents reviewed for hospitalization. The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19. The record identified on 01/17/20 Resident #166 was sent to the hospital and admitted with a fractured hip. The record revealed a lack of bed hold policy notification at the time of hospital discharge. The record identified Resident #166 remained in the hospital from [DATE] through 01/22/20. Review of Resident #166's financial records revealed the resident paid privately for her nursing home stay. She was charged a bed hold for each day she was not in the facility during her hospital admission. Interview on 02/05/20 at 2:06 P.M., Fiscal Office [NAME] #71 stated she was only responsible to complete bed hold notifications for residents whom receive Medicaid. Fiscal Office [NAME] #71 confirmed she has no evidence Resident #166 and or her family had approved and or requested for her bed to be held, however she was charged the bed hold while she was in the hospital. Interview with Resident #166's daughter on 02/05/20 at 3:20 P.M. confirmed neither herself or Resident #166 were provided the bed hold policy and choice if they wanted to hold Resident #166's bed at the time of her discharge. Resident #166's daughter indicated she would not want to pay $200 a day, when her mother was not in the building getting care. Review of the facility policy titled Bed Hold Policy, dated 04/19, identified if the resident's payer source is one other than Medicaid, the resident or their sponsor will contact the facility if they will be holding the bed via telephone and or in person on the next business date following admission to the hospital. Facility at that time inform them of their financial responsibility in regards to the bed hold option. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 4 of 8 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 02/06/2020 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 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, resident interview, family interview, and staff interviews, the facility failed to ensure residents were invited to participate in their care planning meetings. This affected one (#166) of four residents reviewed for participation in care planning. The facility census was 119. Findings include: Review of Resident #166's medical record identified admission to the facility occurred on 11/30/19 following hospitalization. Diagnosis included pathological fractures of the right foot, The facility admission assessment dated [DATE] revealed Resident #166 was cognitively intact. The record contained no evidence Resident #166 had been invited to participate in care planning. Interview on 02/03/20 at 3:13 P.M., Resident #166 stated she had never been invited nor attended her care plan meetings, but would if she was asked. Interview on 02/05/20 at 9:18 A.M., Licensed Social Worker (LSW) #87 identified the Minimum Data Set nurse completed the schedule for care planning conferences and she was in charge of inviting residents/families to the meetings. LSW #87 confirmed she a care plan meeting occurred for Resident #166 on 12/18/19. There was no evidence the family and or Resident #166 attended and or was invited to participate in the meeting. LSW #87 identified the care planning meetings are usually completed in the computer chart, however there were none in the computer for Resident #166. A telephone interview with Resident #166's daughter on 02/05/20 at 3:14 P.M. confirmed she had never been invited to attend any meetings regarding her mother's care. Resident #166's daughter stated her and her mother would attend any meetings regarding care and/or treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 5 of 8 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 02/06/2020 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, medical record review, and staff interviews, the facility failed to follow physician orders for the application of a boot to the lower extremity for one (#1) of five residents reviewed for skin conditions. The facility census was 119. Residents Affected - Few Findings include: Review of Resident #1's medical record identified admission to the facility occurred on 06/17/17. Diagnoses included diabetes, peripheral vascular disease, above the knee amputation and hemiplegia. Review of Resident #1's physician orders identified the use of a zero gravity boot to the left foot at all times. Observation on 02/04/20 at 11:22 A.M. revealed Resident #1 was sitting in a tilt back wheelchair which had medal foot pedals on both sides of the chair. Resident #1 did not have a zero gravity boot on the left foot. Resident #1 left foot was turning into the right side and is toes were hitting the right foot pedal. Interview on 02/04/20 at 11:36 A.M., State Tested Nursing Assist (STNA) #48 confirmed Resident #1 should have a zero gravity boot on his left foot. The STNA stated she had placed the boot in the laundry this morning and she could not locate another one to place on the resident. The STNA confirmed Resident #1 has all the skin torn off the top of his third toe on the left foot. Observation on 02/04/20 at 2:07 P.M. revealed Resident #1 had a dressing to his left third toe. Interview on 02/04/20 at 2:07 P.M. Licensed Practical Nurse (LPN) #107 confirmed Resident #1 did not have a current physician order for a dressing and she was not aware of when the dressing was applied. The interview confirmed Resident #1 has the skin removed from the top of his left third toe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 6 of 8 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 02/06/2020 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based of review of a nurse's note, review of a vision provider note, review of an Eye Glass Tracker form, review of a Vision Care form, staff interviews, and review of facility policy, revealed the facility failed to timely follow up with a vision care provider regarding ordered eye glasses not yet received. This affected one (#91) of one resident reviewed for vision care services. The facility census was 119. Residents Affected - Few Finding included Review of the medical record revealed Resident #91 had an admission date of 02/07/18. Diagnoses included heart failure, dysphagia, major depressive disorder, and diabetes mellitus type two. Review of the annual Minimum Data Set (MDS) assessment, dated 01/01/20, revealed the resident had impaired cognition. Further review of the assessment noted resident had no corrective lenses. Review of a nurse's note dated 10/15/19 10:09 A.M. revealed laundry staff found the resident's eye glasses in the dryer. A screw was missing and one of the lenses was missing. Review of a vision provider note dated 10/17/19 revealed the resident was seen for a diabetic eye exam. The resident was evaluated for blurry vision in the right and left eyes. Eye glasses were ordered for the resident pending insurance/payor approval. Review of a facility Eye Glass Tracker form, dated 10/17/19, revealed Resident #91 was one of three residents who had ordered glasses from the facility's eye care provider. Two of the three residents had received their eye glasses. Resident #91 had not received her eye glasses. Review of a hand written note on the form documented Never got, lost. Review of a Vision Care form revealed the facility checked on the status of the glasses on 11/28/19 and noted the glasses were still in process. Further review of the Vision Care form revealed the facility had not followed up with the vision provider regarding the status of the resident's glasses until 01/28/20. The facility noted on 02/04/20 the glasses would not arrive for another seven to ten days. Interview on 02/04/20 at 1:48 P.M. with Licensed Social Worker (LSW) #87 revealed Resident #91's new eye glasses were ordered in 10/2019. LSW #87 verified the resident had not yet received her eyeglasses. Interview on 02/04/20 at 2:24 P.M. with the Medical Records Supervisor (MRS) #81 revealed the resident's glasses were ordered on 10/17/19. MRS #81 verified the resident had not received the new eyeglasses. MRS #81 verified the facility had not followed up with the vision provider from 11/22/19 until 01/28/20. MRS #81 first stated the glasses were in process, then MRS #81 stated the vision provider indicated the glasses were sent to the facility but were lost. MRS #81 later revealed the new eye glasses had not been lost but there was an issue with the laboratory manufacture of the eyeglasses. Review of the policy titled Vision Services, dated 05/2018, revealed routine and emergency vision services were available to meet the resident's vision health services in accordance with the resident's assessment and plan of care. Further review of the policy revealed social services personnel would be responsible for assisting the resident/family with vision services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 7 of 8 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 02/06/2020 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, review of dietary menus, review of dietary spreadsheets, and staff interviews, the facility failed to serve the identified portion sizes of pureed chicken to 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets. The facility census was 119. Findings include: Review of the menu for the lunch meal on 02/03/20 identified the facility was serving chicken, mashed potatoes and green beans. Review of the spreadsheets for the lunch meal on 02/03/20 revealed pureed diets should receive a #10 scoop of pureed chicken. The facility provided a listing that identified size #10 scoop is equal to 3/8 cup or 3 ounce. Observation on 02/05/20 at 11:49 A.M., [NAME] #114 was plating the noon meal. [NAME] #114 was observed to be utilizing a two ounce scoop for the pureed chicken for each of the residents receiving pureed diets. Interview on 02/05/20 at 12:02 P.M., [NAME] #114 confirmed she was not aware the facility menus had portion sizes listed and she just uses the same scoops for each meal. Interview on 02/05/20 at 12:04 P.M., Dietary Manager #115 confirmed the staff were not following the menu and spreadsheet for proper portion sizes. The facility identified 12 residents (#4, #5, #9, #16, #23, #57, #59, #65, #76, #80, #93 and #94) who received pureed diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 8 of 8