Health inspection·March 16, 2023

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #52's physician orders for March 2023 identified orders for small portions diet with regular texture and regular consistency including full fat Greek yogurt with breakfast and lunch, Magic Cup with breakfast and lunch, Mighty Shake two times per day for supplement, and Boost Breeze one time per day with breakfast for supplement. Observation of the lunch meal on 03/14/23 beginning at 12:29 P.M. revealed Resident #52 was served a deli-style sandwich which was cut in half, sliced green apples, cooked carrots, and apple sauce. The resident finished eating and staff assisted her out of the dining room. Resident #52 did not receive a Magic Cup or Greek yogurt with the lunch meal. Observation of Resident #52's lunch meal ticket revealed the resident was to receive full-fat Greek yogurt with lunch. The meal ticket did not mention the Magic Cup. Interview on 03/14/23 at 1:00 P.M. with Dietary Manager #600 verified Resident #52 received a Magic Cup or Greek yogurt with her lunch meal. An unidentified State Tested Nurse Aide (STNA) sitting next to where Resident #52 had been seated also verified she did not believe Resident #52 received a Magic Cup or Greek yogurt with her lunch meal. Observation of the breakfast meal on 03/15/23 beginning at 8:06 A.M. revealed Resident #52 never received Greek yogurt or Boost Breeze with her breakfast meal. Resident #52 finished eating breakfast and was assisted out of the dining area by staff. Observation of Resident #52's breakfast meal ticket revealed Boost Breeze was not listed on the ticket. Full-fat Greek yogurt with breakfast was listed on the meal ticket. Interview on 03/15/23 at 8:54 A.M. with Dietary Aide #602 verified Resident #52 did not receive Greek yogurt with the breakfast meal. Dietary Aide #602 stated the Greek yogurt was stored in ice on top of the tray cart containing resident meal trays and staff must have forgotten to grab it. Dietary Aide #602 also verified Resident #52 did not receive the Boost Breeze supplement with her meal. Dietary Aide #602 reported Resident #52 never received Boost Breeze with breakfast and verified the breakfast meal ticket did not mention the Boost Breeze supplement. Observation of the lunch meal on 03/15/23 at 12:27 P.M. revealed Resident #52 did not receive a Magic Cup or Greek yogurt with the lunch meal. Resident #52 was assisted out of the dining room by staff. Interviews and observations on 03/15/23 at 1:07 P.M. with STNA #559, STNA #578, STNA #584, and Dietary Aide #584 revealed staff were in the dining area near where Resident #52 was seated for the lunch meal. All four staff members stated Resident #52 did not receive a Magic Cup with her lunch meal and only with her breakfast meal. Observation of Resident #52's lunch meal ticket revealed the Magic Cup was not listed on the ticket. Interview on 03/15/23 at 1:40 P.M. with Dietitian #610 verified Resident #52 was supposed to receive a Magic Cup with the breakfast, lunch, and dinner meals, full-fat Greek yogurt with the breakfast and lunch meals, and a Boost Breeze supplement with the breakfast meal. Dietitian #610 was notified Resident #52 had not received the aforementioned items with meals. Upon review of Resident #52's standing orders and meal tickets, Dietitian #610 reported the Magic Cup had not been showing up on Resident #52's lunch meal ticket because there were numerous other items listed on the ticket and there was not enough room on the ticket. Interviews on 03/15/23 at 2:52 P.M. with MDS Coordinator #522 and Dietitian #610 revealed Licensed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 2 of 7 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 03/16/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Practical Nurse (LPN) #528 was contacted and reported Resident #52 sometimes received the Boost Breeze supplement while in a sitting area on the 300-unit prior to the breakfast meal. 2. Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with admitting diagnoses including Alzheimer's Disease, need for assistance with personal care and unspecified severe protein-calorie malnutrition. The MDS quarterly assessment dated [DATE] revealed the Resident #39 had severe cognitive impairment. The assessment revealed the resident required limited assistance for bed mobility, transfers, walking in his room or in the corridor, and locomotion on or off from the unit. The assessment revealed the resident required extensive assistance for personal hygiene, dressing and toileting. The assessment revealed the resident required supervision for eating, with physical assistance at times by one person. The care plan dated 01/01/23 revealed Resident #39 had a severely impaired cognitive function with interventions which included administer medications as ordered ask yes/no question to determine the resident's needs; and cue, reorient and supervise as needed. The care plan revealed the resident had nutritional problem or potential nutritional problem related partially to Alzheimer's Disease, with interventions which included to assess diet tolerance; assist resident with meals as needed, and encourage resident to eat or drink; and provide diet per order. This care plan also revealed a recommendation dated 12/12/22 for Boost supplemental drink served three times daily with meals due to significant weight loss. Medical record review for Resident #39 revealed a recorded weight on 03/01/23 of 145.6 pounds, and a recorded weight on 02/07/23 of 145.1 pounds, equaling a 0.34% weight gain within 30 days. The record showed a recorded weight on 09/01/22 of 153.0 pounds equaling a 4.84% weight loss within 180 days. Further medical records review for Resident #39 revealed an order for Boost was initiated on 12/12/22. On 03/13/23 at 12:34 P.M. an observation was made of Resident #39 seated at a table in the dining area on the secured memory unit. Resident #39 was seated at a table with only one other resident. Resident #39 was observed to have a soup bowl, a lunch meal on a plate, a small disposable container of pudding, and a small can of soda, which staff opened for Resident #39 and poured into a small, clear plastic cup. There were no supplemental food items served to Resident #39. It was observed Resident #39 had not consumed any food from the lunch meal plate. Resident #39 had consumed the pudding in total. Resident #39 had consumed 75-100% of the soup. Resident #39 drank all the soda which had been poured into the clear plastic cup. On 03/14/23 at 12:17 P.M. an observation was made on the secured memory care unit of the lunch meal delivery cart arrival. Staff immediately began delivering the lunch meals to residents. An observation was made of residents at the tables who were consuming a food item from a bowl, later identified as the soup for the day. Resident #39 was not located in the dining area. A staff member was heard at the entry to Resident #39's room, announcing the lunch meal was being served, and the staff member asked Resident #39 to come to the dining area. At 12:24 P.M. on 03/14/23 Resident #39 emerged from his room and ambulated to the dining area to sit for his lunch meal. Resident #39 did not receive a soup. Resident #39 received a lunch meal plate, an ice cream cup, and a small can of soda which a staff member opened and poured into a small clear plastic cup. There was no supplemental food item served with Resident #39's lunch meal. Resident #39 was observed to pick at the food on his plate. Resident #39 was observed to consume the ice cream in total. Resident #39 was observed to drink the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 3 of 7 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 03/16/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few soda from the cup. Resident #39 picked up his eating utensil several times and moved items about on his lunch plate. At 12:53 P.M., Resident #39's plate was observed to have no food taken from the plate by the resident. The ticket which accompanied Resident #39's meal was observed to read Boost eight ounces (oz). In an interview with State Tested Nurse Aide (STNA) #570 on 03/14/23 at 12:53 P.M. an inquiry was made about the supplemental food item (Boost) on the meal ticket for Resident #39. STNA #570 looked at the meal ticket for Resident #39 and stated she thought she had given Resident #39 a Boost with his lunch meal. STNA #570 verified Resident #39 had not received Boost supplement with his lunch meal. STNA #570 then stated she did not know he was supposed to get Boost with his meals. Review of facility policy titled Philosophy and Standards of Clinical Care, dated 2021, revealed the facility would develop and consistently implement pertinent food and nutrition interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 4 of 7 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 03/16/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to maintain accurate medical records regarding documentation for nutritional supplements. This affected one (#52) of two residents reviewed for nutrition. The facility census was 95. Findings include: Review of Resident #52's medical record identified the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus without complications, iron deficiency, dementia, age-related osteoporosis, depression, anxiety, muscle weakness, and cognitive communication deficit. Review of Resident #52's current plan of care, revised 02/15/23, revealed the resident had a nutritional problem related to fracture of left femur, physical disability, fracture of left humerus, anemia, hypoosmolality/hyponatremia, therapeutic diet order for small portions per request, assist with meals, upper and lower dentures, history of falling, eats fifty-percent or less, advanced age, meal and/or supplement refusals, significant weight loss, decreasing weight trend, and resistant of staff encouragement at meals and with care. Goals included no significant weight changes and remaining free from dehydration as evidenced by good skin turgor, labs, etcetera. Interventions included monitoring percent of meals consumed, and supplements as ordered. Review of Resident #52's quarterly Minimum Data Set 3.0 assessment, dated 03/09/23, revealed the resident was severely cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident required supervision of one staff for eating. The resident experienced weight loss of five-percent or more in the past month or loss of ten-percent or more in the last six months and was not on a prescribed weight-loss regimen. Review of Resident #52's dietary progress notes dated 03/10/23 revealed the resident sustained significant weight loss times six months, supplements and extra foods in place, Greek yogurt in place twice per day with breakfast and lunch for additional calories and protein, resident refused meals and supplements at times, Magic Cup supplement in place three times per day with meals, no edema, skin intact, and will continue to monitor. Review of Resident #52's physician orders for March 2023 identified orders for Magic Cup with breakfast and lunch, and Boost Breeze one time per day with breakfast for supplement. Review of Resident #52's intake record, dated 03/14/23 at timed 11:08 A.M., revealed the resident was documented as consuming between fifty-one percent and seventy-five percent of her lunch magic cup. Review of Resident #52's Medication Administration Record (MAR) for March 2023 revealed the resident was documented as receiving her Magic Cup with the lunch meal on 03/14/23. Review of Resident #52's intake record, dated 03/15/23 and timed 7:03 A.M. revealed the resident was documented as consuming between fifty-one and seventy-five percent of the Boost Breeze supplement. Review of Resident #52's MAR for March 2023 revealed the resident was documented as receiving her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 5 of 7 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 03/16/2023 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 0842 Boost Breeze supplement with the breakfast meal on 03/15/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #52's intake record dated 03/15/23 and timed 1:41 P.M. revealed the resident was documented as consuming between twenty-six percent and fifty-percent of her lunch magic cup. Residents Affected - Few Review of Resident #52's MAR for March 2023 revealed the resident was documented as receiving her Magic Cup with the lunch meal on 03/15/23. Observation of the lunch meal on 03/14/23 beginning at 12:29 P.M. revealed Resident #52 did not receive a Magic Cup with the lunch meal. Observation of Resident #52's lunch meal ticket revealed the meal ticket did not mention the Magic Cup. Interview on 03/14/23 at 1:00 P.M. with Dietary Manager #600 verified Resident #52 received a Magic Cup with her lunch meal. An unidentified State Tested Nurse Aide (STNA) sitting next to where Resident #52 had been seated also verified she did not believe Resident #52 received a Magic Cup with her lunch meal. Observation of the breakfast meal on 03/15/23 beginning at 8:06 A.M. revealed Resident #52 never received the Boost Breeze supplement with her breakfast meal. Resident #52 finished eating breakfast and was assisted out of the dining area by staff. Observation of Resident #52's breakfast meal ticket revealed Boost Breeze was not listed on the ticket. Interview on 03/15/23 at 8:54 A.M. with Dietary Aide #602 verified Resident #52 did not receive the Boost Breeze supplement with her meal. Dietary Aide #602 reported Resident #52 never received Boost Breeze with breakfast and verified the breakfast meal ticket did not mention the Boost Breeze supplement. Observation of the lunch meal on 03/15/23 at 12:27 P.M. revealed Resident #52 did not receive a Magic Cup with the lunch meal. Resident #52 was assisted out of the dining room by staff. Interviews and observations on 03/15/23 at 1:07 P.M. with STNA #559, STNA #578, STNA #584, and Dietary Aide #584 revealed staff were in the dining area near where Resident #52 was seated for the lunch meal. All four staff members stated Resident #52 did not receive a Magic Cup with her lunch meal and only with her breakfast meal. Observation of Resident #52's lunch meal ticket revealed the Magic Cup was not listed on the ticket. Interview on 03/15/23 at 1:40 P.M. with Dietitian #610 verified Resident #52 was supposed to receive a Magic Cup with the breakfast, lunch, and dinner meals, and a Boost Breeze supplement with the breakfast meal. Dietitian #610 was notified Resident #52 had not received the aforementioned items with meals. Upon review of Resident #52's standing orders and meal tickets, Dietitian #610 reported the Magic Cup had not been showing up on Resident #52's lunch meal ticket because there were numerous other items listed on the ticket and there was not enough room on the ticket. Interviews on 03/15/23 at 2:52 P.M. with MDS Coordinator #522 and Dietitian #610 revealed Licensed Practical Nurse (LPN) #528 was contacted and reported Resident #52 sometimes received the Boost Breeze supplement while in a sitting area on the 300-unit prior to the breakfast meal. A follow-up interview on 03/16/23 at approximately 4:50 P.M. with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Dietitian #610, revealed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366072 If continuation sheet Page 6 of 7 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 03/16/2023 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 0842 had identified the issue regarding meals, supplements and accurate documentation. 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: 366072 If continuation sheet Page 7 of 7