Inspection·January 17, 2019

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and staff interview, the facility failed failed to ensure privacy was maintained during incontinence care for one (#11) of one resident observed for incontinence care. The facility identified 39 residents that are incontinent of bladder and 23 residents who area incontinent of bowel that would require incontinence care. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 3/10/14. Diagnoses included colitis, atrial fibrillation, anemia, syncope, peripheral vascular disease, arthritis, overactive bladder, and peripheral edema. Review of the Minimum Data Set (MDS) assessment, revealed Resident #11, had severe cognitive impairment. Resident #11 was frequently incontinent of bladder and always incontinent of bowel. Observation on 1/16/19 at 11:34 A.M. of State Tested Nurse Aide (STNA) #150 and STNA #155 performing perineal (peri) care for Resident #11 revealed during the peri care someone knocked on the door. Both STNA #150 and STNA #155 responded Resident care. Environmental Services #160 opened the door, entered the room, and noted the STNAs were in the middle of peri care. Environmental Services #160 went back out into the hallway, left the door open, and reentered the room with blankets. Environmental Service #160 laid the blankets on Resident #11's tray table. Resident #11's buttocks were exposed towards the door. Interview on 1/16/19 at 11:36 A.M., STNA #150 and STNA #155 both verified they had stated Resident care when someone knocked at the door. Both verified they did not give permission to enter the room. STNA #150 stated this happens all the time. Interview on 1/16/19 at 11:42 A.M., Environmental Services #160 verified she came in the room after the STNAs said Resident care. Environmental Services #160 stated she knew she should not have entered the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 2 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to provide a notice of transfer when residents were transferred to the hospital This affected two (#26, #66) of two residents reviewed for hospitalizations. The facility identified four residents discharged to the hospital in the last 30 days. The facility census was 67. Findings include: 1. Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included deep vein thrombosis, gastro-esophageal reflux disease, glaucoma, macular degeneration, hypertension, shortness of breath, atrial fibrillation, bilateral diabetic heel ulcers status debridement, diabetes mellitus, end stage renal disease, coronary artery disease, congestive heart failure, degenerative disc disease, chronic osteomyelitis, left above knee amputation, right second toe amputation and sepsis. Review of an annual Minimum Data Set (MDS) 3.0 assessment, dated 11/01/18, revealed the resident had no cognitive deficits or rejection of care, required extensive assistance for bed mobility, transfers, locomotion, dressing, toileting and hygiene. Review of the Fulton Manor Nursing and Rehabilitation to Hospital Transfer Form, dated 07/24/18, revealed the resident was sent to the hospital on [DATE] due to chest pain. The bottom right corner had Date Sent: 07/24/18 but did not say to whom. Review of a Status Memo dated 07/24/18 revealed notification was sent regarding the transfer on 07/24/18 but did not reveal to whom. Review of the Fulton Manor Nursing and Rehabilitation to Hospital Transfer form dated 11/0718 revealed the resident was transferred to the hospital on [DATE]. The bottom right corner had Date Sent: 11/08/18 but did not say to whom. Review of progress notes dated 07/23/18 through 07/27/18 and 11/07/18 through 11/11/18 revealed no documentation regarding a notice of transfer being given to the resident or resident family. Interview with Resident #26 on 01/14/19 at 11:40 A.M. revealed she had not received a notice of transfer when she had been transferred to the hospital. Interview Social Service Worker #85 on 01/16/19 at 3:00 P.M. verified Resident #26's responsible party was notified of the transfer by phone at the time of the transfer and a written form was sent on 07/24/18 and 11/08/18. She stated there was nothing in the facility to document this occurred. She verified the transfer form showed the date the form was sent but not to whom. She verified the resident was not given a notice of transfer for 07/24/18 or 11/08/18. Review of the undated facility policy titled Notice of Transfers revealed the resident, representative, Ohio Department of Health legal, and Ohio ombudsman were to be sent a notice when a resident was transferred to the emergency room or admitted to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 3 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0623 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #66 revealed an admission date of 12/06/18 and a discharge date of 12/14/18. Diagnoses included chronic obstructive pulmonary disease, acute congestive heart failure, dyspnea, unspecified, chronic lympoid leukemia, coronary artery disease involving native coronary artery without angina pectoris, grave's disease, history of right breast cancer, diabetes mellitus type 2, hypothyroidism, and hypertension. Residents Affected - Few Review of the hospital transfer form dated 12/14/18 revealed Resident #66 was transferred the hospital due to being short of breath. The form indicated the date sent was 12/14/18. The form does not state where it was sent. Interview on 1/17/19 at 2:19 P.M. with Social Service Worker #85 verified a written transfer form was sent to the family, but not the resident. The facility has no proof of documentation to verify they sent this notice to the family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 4 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 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. Based on medical record review, staff interview, and policy review, the facility failed to provide a bed hold notice to one (#66) of two residents reviewed for hospitalization. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #66 revealed an admission date of 12/06/18. Diagnoses included chronic obstructive pulmonary disease, acute congestive heart failure, dyspnea, unspecified, chronic lympoid leukemia, coronary artery disease involving native coronary artery without angina pectoris, Grave's disease, history of right breast cancer, diabetes mellitus type 2, hypothyroidism, and hypertension. Review of the hospital transfer form dated 12/14/18 revealed Resident #66 was transferred the hospital due to being short of breath. Further review revealed no record of a bed hold notice given to Resident #66 and/or resident representative. Interview with Business Office Manager on 01/17/19 at 11:00 A.M. verified bed hold notices were not provided to private pay residents or to those residents who received Medicare part A skilled services. She stated bed hold notices were provided to the responsible parties of residents who received Medicaid services and did not get provided to the residents unless they were their own responsible party. Interview with Business Office Manager on 1/17/19 at 2:10 P.M. verified Resident #66 and the representative did not receive a bed hold notice when she was discharged from the facility on 12/14/18. Review of the undated policy titled Bed Hold revealed the bed hold procedure as follows for Medicare bed hold included the nurse will notify the Business Office when a resident leaves the facility, including time of day and transportation method. The facility will notify the resident or family when there is a need for the bed being held at no charge. The family at that point will need to decide to pay to hold the bed or release the bed to the other resident. The policy indicates for private pay bed hold the residents are notified upon admission beds are held automatically at 100% of the daily rate if a resident leaves the facility for any reason. It is the responsibility of the resident or family to notify the facility if the bed is not to be held. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 5 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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, staff interview, and review of facility policy, the facility failed to accurately document the terminally ill status of a resident on the Minimum Data Set assessment for one (#34) of 18 residents who had an reviewed. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #34 revealed the resident was admitted to the facility on [DATE]. Diagnoses included degenerative disease of the nervous system, dysphagia, unsteadiness, muscle weakness, supranuclear opthalmoplegia, Steel-[NAME]-[NAME] palsy syndrome, urinary tract infections, atrial fibrillation, chronic obstructive pulmonary disease, cerebrovascular disease, coronary artery disease and Parkinson's disease. Review of physician orders dated 09/12/18 revealed the resident was admitted to hospice with a primary diagnosis of progressive supranuclear palsy Review of the hospice documentation dated 09/12/18 revealed the physician certified the resident's prognosis was six months or less if the disease ran its normal course. A diagnoses of Parkinson's disease was listed. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment,dated 11/15/18, revealed the resident had severe cognitive deficits. Section J1400 revealed the resident did not have a terminal diagnosis. Interview with MDS Nurse #175 on 01/17/19 at 2:00 P.M. verified Resident #34's MDS was not coded as having a terminal illness. Review of an undated facility policy titled MDS Process Policy revealed each department was responsible for completing their section of the MDS timely and accurately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 6 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 medical record review, resident interview, staff interview, family interview, and policy review, the facility failed to monitor the bowel regimen for two ( #50 and #314) of five residents reviewed for bowel regimen. The facility census was 67. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 10/26/18. Diagnoses included cardiomyopathy, chronic obstructive pulmonary disease, constipation, urinary retention, vascular dementia, coronary artery disease, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/17/18, revealed Resident #50 had mild cognitive impairment. Review of the current physician orders revealed an order for Dulcolax suppository 10 milligrams (mg) daily as needed, Milk of Magnesia 30 milliliters (ml) daily as needed, Miralax 17 grams daily as needed. Review of the bowel monitoring records for Resident #50 revealed there was no bowel movement recorded from 11/02/18 thru 11/20/18, 11/21/18 thru 11/29/18, 12/16/18 thru 12/22/18, and 01/10/19 thru 01/17/19. Review of the progress notes for Resident #50 revealed a note dated 12/05/18 documenting the resident was on bowel list for no bowel movement. Resident #50 told staff that he had a bowel movement on 12/04/18. Progress note dated 1/08/19 revealed Resident #50 was complaining of constipation, and not being able to have a bowel movement after multiple tries. Resident #50 requested something. Milk of Magnesia with prune juice was given. Suppository was given following no results from the Milk of Magnesia. Results were obtained following the suppository. Interview on 1/17/19 at 9:47 A.M., Resident #50 revealed he did not recall how long he had gone without having a bowel movement, but stated he knows sometimes it has been awhile. Interview on 1/17/19 at 12:06 P.M., the Director of Nursing (DON) revealed the facility does not have a way to track resident's bowel movements. The DON stated that it is the protocol for the night shift nurse to check each resident's bowel movement pattern and to initiate the bowel protocol if the resident has not had a bowel movement in two days. The DON verified Resident #50 did not have a bowel movement documented from 11/02/18 thru 11/20/18, 11/21/18 thru 11/29/18, 12/16/18 thru 12/22/18, and 01/10/19 thru 01/17/19. 2. Review of the medical record for Resident #314 revealed an admission date of 12/31/18. Diagnoses included gangraneous changes right foot, diabetes mellitus type one, coronary artery disease, atrial fibrillation, chronic kidney disease stage four, hydronephrosis, heart failure, hypertension, hyperlipidemia, and osteoarthritis. Review of Resident #314's current physician orders revealed orders for Milk of Magnesia 30 ml daily as needed and Dulcolax suppository 10 mg rectally daily as needed. Review of the bowel monitoring record for Resident #314 revealed they did not have a bowel movement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 7 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 documented from 01/01/19 thru 01/07/19 and 1/13/19 thru 1/17/19. Level of Harm - Minimal harm or potential for actual harm Review of the progress notes for Resident #314 revealed no documentation of bowel movements or interventions given from 01/01/19 thru 1/07/19 and 1/13/19 thru 1/17/19. Residents Affected - Few Interview on 1/16/19 at 9:15 A.M., Resident #314's family stated they are unsure if Resident #314 had been having bowel movements regularly. Family stated Resident #314 was not reliable to answer that question either. Interview on 1/16/19 at 11:37 A.M., State Tested Nurse Aide (STNA) #150 said if a resident has a bowel movement they document it in the computer or on the 24 hour care sheet. STNA #150 said they are unable to see if a resident has had a bowel movement in the prior days when documenting. Interview on 1/17/19 at 12:06 P.M., the DON verified that Resident #314 has not had a bowel movement documented from 1/01/19 thru 1/07/19 and 1/13/19 thru 1/17/19. Review of the undated facility policy titled Bowel Protocol revealed residents will be monitored daily for bowel function. Each shift the charge nurse will remind the STNA to complete bowel movement documentation on the nursing assistant 24 hour report sheet, day one, two, three, and four and appropriate laxative to be given. Each charge nurse will be responsible to follow physician orders as indicated. If a resident is consistently constipated, review medications with physician for need of a stool softener or additional routine medications. If no bowel movement in two days, give prune juice four ounces with breakfast. If no bowel movement for three days, give four ounces prune juice and milk of magnesia 30 ml with breakfast. If no bowel movement for four days give dulcolax suppository rectal after breakfast, but prior to lunch. If no bowel movement with four hours after the dulcolax suppository, give fleets enema rectal on the evening shift. Contact the physician if the above protocol is not effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 8 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, medical record review, and staff interview, the facility failed to ensure medications were not left unsupervised in a resident's room. This had the potential to affect ten residents (#5, #6, #7, #8, #37, #42, #60, #66, #165, and #167) on the 200 Wing who were confused and independently ambulatory. The facility census was 67. Findings include: Observation on the 200 Wing of Resident #38's room on 01/14/19 at 10:49 A.M. revealed a medication cup containing eight pills sitting on the bedside table in front of the resident. Review of the medical record revealed the medications in Resident #38's room were the bladder relaxant oxybutynin, potassium chloride, sennalax, acidophilus, antianxiety medication buproprion, docusate, ferrous sulfate, and the diuretic furosemide. Interview with Registered Nurse #100 on 01/14/19 at 1:01 P.M. verified she left Resident #38's medications in her room and should not have left the medications unattended. The facility identified ten residents (#5, #6, #7, #8, #37, #42, #60, #66, #165, and #167) on the 200 Wing who were confused and independently ambulatory. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 9 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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, review of facility policy, resident interview, and staff interview, the pharmacist failed to acknowledge indefinite use of an antibiotic during the monthly drug regimen review. This affected one resident (#18) of five residents reviewed for unnecessary medications. The facility identified nine residents who currently received antibiotics. The facility census was 67. Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, Parkinson's disease, left patellar (knee) repair, deep vein thrombosis right arm axilla, mesothelioma, bleeding gastric ulcer, gastro-esophageal reflux disease, and pressure ulcers. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/25/18, revealed the resident had no cognitive deficits. Antibiotics were used for all seven days of the assessment period. Review of physician orders dated 09/13/17 revealed the resident had been started on levofloxacin ( antibiotic) 500 milligrams (mg) by mouth daily for an indefinite period. No diagnosis was provided for the use of the antibiotic. Review of physician progress notes in the medical record dated 12/2017 to 01/18/19 revealed no mention of the antibiotic. Review of pharmacy recommendations revealed no recommendations had been brought to the physician's attention regarding no diagnosis for the continued levofloxacin or rationale for its continued use. Review of the Monthly Medication Regimen Review revealed the pharmacist had reviewed the resident's chart monthly between 12/2017 and 01/2019. Use of an indefinite antibiotic was not listed at any time. Review of Medication Administration Records dated 10/2018, 11/2018, 12/2018 and 01/2019 revealed the levofloxacin 500 mg had been given daily as ordered. Interview with Resident #18 on 01/16/19 at 11:00 A.M. revealed he felt good and did not feel like he had an infection. Interview with the Director of Nursing on 01/17/19 at 1:00 P.M. verified there was no documentation on the pharmacist monthly medication regimen review to acknowledge the ongoing use of levofloxacin since the residents admission. She further verified the pharmacist was to monitor the use of antibiotics and be sure there was a justifiable diagnosis for its use. Review of facility policy titled Medication Regimen Review, dated 11/28/16, revealed the consulting pharmacist was to perform a comprehensive review of each resident's medication regimen at least monthly. This was to include an evaluation of the resident's response to medication therapy to determine the resident maintained the highest practicable level of functioning while preventing or minimizing adverse consequences related to medication therapy. Recommendations were to be reported to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 10 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 Director of Nursing, attending practitioner, the attending practitioner, the medical director and /or the administrator. The resident's drug regimen was to be free from unnecessary medications, which was any medication used in excessive dose, excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of any adverse consequences. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 11 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, review of facility policy, resident interview, review of McGreer definitions of infection, and staff interview, the facility failed to provide justification for the long term antibiotics use for one (#18) of five residents reviewed for unnecessary medications. The facility identified nine residents on antibiotics. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, Parkinson's disease, left patellar (knee) repair, deep vein thrombosis right arm axilla, mesothelioma, bleeding gastric ulcer, gastro-esophageal reflux disease, and pressure ulcers. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/25/18, revealed the resident had no cognitive deficits. Antibiotics were used for all seven days of the assessment period. Review of physician orders dated 09/13/17 revealed the resident had been started on levofloxacin ( antibiotic) 500 milligrams (mg) by mouth daily for an indefinite period. No diagnosis was provided for the use of the antibiotic. Review of attending physician progress notes in the medical record dated 12/2017 to 01/18/19 revealed no mention of the antibiotic. Review of orthopedic physician progress notes dated 05/14/18 revealed a history for the resident of an infection of the left lower leg on 07/26/16. Review of nursing progress notes dated 12/2017 through 01/17/19 revealed the resident had no signs of infection, no fever, no redness or swelling of the leg, or acute changes in mental status. Review of the Monthly Medication Regimen Review revealed the pharmacist had reviewed the resident's chart monthly. Use of an indefinite antibiotic was not listed at any time. Review of Medication Administration Records dated 10/2018, 11/2018, 12/2018 and 01/2019 revealed the levofloxacin 500 mg had been given daily as ordered. Observation of Resident #18 on 01/16/19 at 11:00 A.M. revealed the resident had no signs of infection. Observation of bilateral knees revealed no swelling or redness. Interview with Resident #18 on 01/16/19 at 11:00 A.M. revealed he felt good and did not feel like he had an infection. Review of the Infection Control Tool dated 07/2018 through 12/2018 revealed Resident #18's levofloxacin was not included in the facility's monitoring of antibiotic usage. Interview with the Director of Nursing on 01/17/19 at 1:00 P.M. verified there was no documentation on the continued use of the levofloxacin for Resident #18 since before he was admitted to the facility. She verified it had not been documented by the attending physician or the orthopedic physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 12 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for over a year. She stated the medication was started by the orthopedic physician well before the resident was admitted and the continued use had not been monitored. She further verified the resident did not have any signs of infection. Review of Surveillance Definitions of Infections in Long Term Care Facilities: Revisiting the McGeer Criteria dated 10/2012 revealed infections and symptoms were to be monitored. Symptoms were to be new or acutely worse, and identification of infections were not to be based on a single piece of evidence. Diagnosis by a physician alone was not sufficient for surveillance definition of infection and must be accompanied with compatible signs and symptoms. Common definitions for infection included fever, acute changes in mental status and acute functional decline. Review of facility policy titled Medication Regimen Review, dated 11/28/16, revealed the consulting pharmacist was to perform a comprehensive review of each resident's medication regimen at least monthly. This was to include an evaluation of the resident's response to medication therapy to determine the resident maintained the highest practicable level of functioning while preventing or minimizing adverse consequences related to medication therapy. Recommendations were to be reported to the Director of Nursing, attending practitioner, the attending practitioner, the medical director and /or the administrator. The resident's drug regimen was to be free from unnecessary medications, which was any medication used in excessive dose, excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of any adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 13 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0760 Ensure that residents are free from significant medication errors. 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 a resident received intravenous antibiotics as ordered to treat a diagnosis of septic urinary tract infection. This affected one (Resident #2) of three residents reviewed for urinary catheters/urinary tract infections. The facility identified nine residents on antibiotics. The facility census was 67. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed an admission date of 12/28/18. He was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included altered mental status, sepsis, urinary tract infection, chronic kidney disease, dehydration, encephalopathy, major depressive disorder, urinary retention with urethral stricture, and diabetes mellitus. Review of the resident's hospital readmission orders dated 01/11/19 revealed the resident was to receive intravenous (IV) vancomycin (antibiotic) 750 milligrams (mg) on Tuesday, Thursday, and Saturday with dialysis for two weeks for a sepsis infection. Review of the resident's baseline care plan revealed he had an alteration in urinary output related to urinary tract infection/sepsis. Review of the resident's dialysis report forms revealed the resident went to dialysis on 01/12/19 and 01/15/19. On 01/12/19, medications/IV fluids received included Epogen and liquacel. On 01/15/19, he received Engerix, Epogen, and heparin. There was no documentation indicating the resident received vancomycin. Review of the resident's facility Medication Administration Record revealed the resident was to receive his vancomycin at dialysis. Continued review of the resident's medical record revealed no indication the facility had notified the dialysis center of the order for vancomycin to be administered during dialysis treatments. Interview with Licensed Practical Nurse (LPN) #115 on 01/17/19 at 11:02 A.M. revealed the resident was to receive his vancomycin at dialysis. She verified the vancomycin administration was not documented on the resident's dialysis report sheets on 01/12/19 or 01/15/19 and it had not been administered by the facility. Telephone interview with Dialysis Administrative Assistant #165 on 01/17/19 at 10:59 A.M. revealed the resident's vancomycin had not been administered with his dialysis treatments. She stated the dialysis center did not have an order for the resident to receive vancomycin. Interview with the Director of Nursing on 01/17/19 at 1:23 P.M. verified there was no documentation indicating the facility notified the dialysis center of the resident's vancomycin order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 14 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0791 Provide or obtain dental services 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, staff interview, resident interview and observation, the facility failed to follow up on dental recommendations for teeth extraction and dentures. This affected one (#26) of one resident reviewed for dental services. The facility identified 12 residents who received dental services from the facility dentist. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed the resident was admitted to the facility on [DATE]. Diagnoses included deep vein thrombosis, gastro-esophageal reflux disease, glaucoma, macular degeneration, hypertension, shortness of breath, atrial fibrillation, bilateral diabetic heel ulcers status debridement, diabetes mellitus, end stage renal disease, coronary artery disease, congestive heart failure, degenerative disc disease, chronic osteomyelitis, left above knee amputation, right second toe amputation and sepsis. Review of an annual comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 11/01/18, revealed the resident had no cognitive deficits. The resident had obvious broken teeth. Review of a Health Care Services consent form dated 11/02/16 revealed the resident had signed the consent to be treated by the facility dentist. Review of a dental exam dated 08/20/18 revealed it was the resident's initial exam. The resident had severe general erosion with no signs of infection. The dentist proposed seven extractions for teeth #2, #3, #9, #10, #12, #19, and #20. No further follow up was available. Interview with Resident #26 on 01/14/19 at 11:40 A.M. revealed she saw the facility dentist several months ago and was told by him that she needed several teeth extracted and then get fit for dentures. She stated she has not heard back from anyone. She indicated she had difficulty at times eating food due to the condition of her teeth. Observation of Resident #26 on 01/14/19 at 11:40 A.M. revealed multiple broken teeth. Interview with Licensed Social Worker (LSW) #250 on 01/16/19 at 11:30 A.M. revealed she was responsible to follow up after resident dental appointments that required additional treatment. She verified Resident #26 was seen by the dentist of 08/20/18 and the LSW was unaware of any additional follow up. She verified the resident was to have teeth extractions and be fitted for dentures. She stated she had not contacted the dentist and was unaware if there were plans for treatment when the dentist visited in 02/2019. Further interview with LSW #250 on 01/16/619 at 11:40 A.M. revealed she had contacted the dentist office who reported they had sent consent forms to the resident's family but they were not returned. She verified she was unaware the resident needed follow up and verified no one had followed up on the dental recommendation for the extractions and dentures. LSW #250 also verified the resident should have been given the form to consent for herself as she was her own responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 15 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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, review of facility logs, review of manufacturer guidelines, and review of facility policies, the facility failed to ensure a facility dishwasher was functioning at the proper wash temperature. In addition, the facility failed to ensure food preparation was conducted in a sanitary manner. These failed practices had the potential to affect all 67 residents. Findings include: 1. During initial tour of the kitchen on 01/14/19 at 8:40 A.M., the facility low temperature dishwasher was observed to have a broken temperature gauge. Review of the facility dishwasher log revealed the wash temperatures were not being monitored. Chemicals were being monitored and were at acceptable ranges. Interview with Dietary Aide #170 on 01/14/19 at 8:40 A.M. verified the facility did not monitor temperatures of the wash cycle, only the chemicals of the final rinse. She verified the temperature gauge was broken. Interview with Dietary Manager #105 on 01/16/19 at 4:25 P.M. verified the facility was not logging temperatures, only chemical levels. She checked the water temperature and it was only getting to 107 degrees, which she verified was not hot enough to meet the guidelines for a low temperature dishwasher, per the manufacturer guidelines. Interview with Food and Nutrition Director #110 on 01/17/19 at 11:30 A.M. verified the manufacturer guidelines required the water temperature to be at a minimum of 120 degrees. He stated the facility was updating the low temperature dishwasher log to reflect the need for a temperature and chemical sanitizer check. Review of the manufacturer's guidelines for the facility low temperature dishwasher revealed general operation instructions included: please follow the instructions given here each shift to assure trouble free operation. Steps included once a proper water level was established, check the temperature of the water (should be minimum 120 degrees Fahrenheit, recommended 140 degrees Fahrenheit). Review of an undated facility policy titled Dish Machine Temperatures revealed all dish machines should have an external thermometer to measure the wash and rinse cycle temperatures. The final rinse of a low temperature dish machine must be between 75 degrees and 120 degrees depending on the sanitizer used. 2. Observation of puree and mechanical ground preparation with [NAME] #90 on 01/16/19 at 10:37 A.M. revealed she began to puree fish and opened the food processor as the fish was not blending correctly. [NAME] #90 used her gloved hands to reach in and break the fish into smaller pieces. At 10:39 A.M., [NAME] #90 picked up fish with her gloved hands and put it into the robocoupe machine. She used her gloved hands to break the fish into pieces. During preparation of the pureed green beans and onions at 10:46 A.M., [NAME] #90 used her gloved hands to scoop green beans from the stainless steel pan they were in. She had previously touched the outside of the food processor, robocoupe and the stainless pans with her gloved hands. During observation of lunch service on 01/16/19 at 11:15 A.M., [NAME] #90 was observed touching the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 16 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 inside of the green bean scoop with her gloved hands to assist the green beans off the scoop. She then used her gloved hands to assist in chopping the green beans into smaller pieces on a resident's plate. [NAME] #90 had previously touched the outside of the holding cart, toaster oven, cupboard doors, and the refrigerator handle. She was then observed using the same gloves to pick up turkey lunch meat, toasted bread, bacon, lettuce, and tomato. There were no utensils available for the bacon, bread, lettuce, lunch meat, or tomatoes. At 11:29 A.M., [NAME] #90 was observed using her gloved hands to break fish up into bite sized pieces on a resident's plate. She took her gloves off and put new gloves on at 11:30 A.M. She then touched the toaster oven and a drawer handle, then proceeded to use her gloved hands to touch bread, lettuce, turkey, and bacon. Interview with [NAME] #90 on 01/19/19 at 11:40 A.M. verified the above findings. Review of a facility policy titled Fulton County Health Center Food Preparation, revised on 11/18, revealed disposable food service gloves and properly sanitized utensils will be used to avoid bare hand contact with ready-to-eat food. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 17 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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, interview, and policy review, the facility failed to wear gloves during eye drop administration. This affected one (5#0) of one resident observed for eye drop administration. The facility census was 67. Residents Affected - Few Findings include: Observation on 1/15/19 at 10:15 A.M. revealed Registered Nurse (RN)#100 administering eye drops, with no gloves on, to Resident #50. RN #100 did perform hand hygiene after eye drop administration. Interview on 1/15/19 at 10:15 A.M., RN #100 verified she did not wear gloves during eye drop administration to Resident #50. Review of the policy titled Standards For Medication Administration, dated 02/2005, revealed gloves will be worn when contact with a resident's body substances, non-intact skin, or mucous membranes is anticipated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 18 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0881 Implement a program that monitors antibiotic use. 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, observation, review of facility policy, resident interview, review of McGreer definitions of infection, and staff interview and staff interview, the facility failed to develop an effective antibiotic stewardship program to monitor antibiotic routine use. This affected one resident (#18) of five residents reviewed for unnecessary medications. The facility identified nine residents on antibiotics. The facility census was 67. Residents Affected - Few Findings include: Review of the medical record for Resident #18 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, Parkinson's disease, left patellar (knee) repair, deep vein thrombosis right arm axilla, mesothelioma, bleeding gastric ulcer, gastro-esophageal reflux disease, and pressure ulcers. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/25/18, revealed the resident had no cognitive deficits, behaviors or rejection of care. Resident #18 required extensive assistance for bed mobility, dressing, toileting, hygiene and was totally dependent for transfers and locomotion. Antibiotics were used for all seven days of the assessment period. Review of physician orders dated 09/13/17 revealed the resident had been started on levofloxacin ( antibiotic) 500 milligrams (mg) by mouth daily for an indefinite period. No diagnosis was provided for the use of the antibiotic. Review of physician progress notes in the medical record dated 12/2018 to 01/18/19 revealed no mention of the antibiotic. Review of orthopedic physician progress notes dated 05/14/18 revealed a history for the resident of an infection of the left lower leg on 07/26/16. Review of nursing progress notes dated 12/2017 through 01/17/19 revealed the resident had no signs of infection, no fever, no redness or swelling of the leg, or acute changes in mental status. Review of the Monthly Medication Regimen Review revealed the pharmacist had reviewed the resident's chart monthly. Use of an indefinite antibiotic was not listed at any time. Review of pharmacy recommendations revealed no recommendations had been brought to the physician's attention regarding no diagnosis for the continued levofloxacin or rationale for its continued use. Review of Medication Administration Records dated 10/2018, 11/2018, 12/2018 and 01/2019 revealed the levofloxacin 500 mg had been given daily as ordered. Observation of Resident #18 on 01/16/19 at 11:00 A.M. revealed the resident had no signs of infection. Observation of bilateral knees revealed no swelling or redness. Interview with Resident #18 on 01/16/19 at 11:00 A.M. revealed he felt good and did not feel like he had an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 19 of 20 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 366097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fulton Manor Nursing & Rehab C 723 South Shoop Avenue Wauseon, OH 43567 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Infection Control Tool dated 07/2018 through 12/2018 revealed Resident #18's levofloxacin was not included in the facility's monitoring of antibiotic usage. Interview with Infection Control Nurse #180 on 01/16/19 at 10:30 A.M. revealed long term antibiotics were not monitored by the infection control committee as they were not thought to be for active infections. She further verified long term antibiotics were not included on the antibiotic/infection log. She stated they were monitored by the physician and pharmacist and she did nothing with them unless asked by the pharmacist. Interview with the Director of Nursing on 01/17/19 at 1:00 P.M. verified there was no documentation on the continued use of the levofloxacin for Resident #18 since before he was admitted to the facility. She verified it had not been documented by the attending physician or the orthopedic physician for over a year. She stated the medication was started by the orthopedic physician well before the resident was admitted and it's continued use had not been monitored. She further verified the resident did not have any signs of infection. Review of Surveillance Definitions of Infections in Long Term Care Facilities: Revisiting the McGeer Criteria dated 10/2012 revealed infections and symptoms were to be monitored. Symptoms were to be new or acutely worse, and identification of infections were not to be based on a single piece of evidence. Diagnosis by a physician alone was not sufficient for surveillance definition of infection and must be accompanied with compatible signs and symptoms. Common definitions for infection included fever, acute changes in mental status and acute functional decline. Review of facility policy Antibiotic Stewardship program dated 10/11/18 revealed the facility was to implement an Antibiotic Stewardship Program (ASP) which would promote appropriate use of antibiotics while optimizing the treatment of infections while reducing the adverse events associated with antibiotic use. The facility was to use the ASP team to review medication and antibiotic use, ensure education and training about antibiotic stewardship was provided to resident care staff, providers and residents and families. A pharmacist was to perform a medication regimen review and assist in oversight of antibiotic prescribing and report situations with questionable indications to the Director of Nursing and attending physician. Antibiotic orders were to include a dose, duration and indication for use and the team was to conduct surveillance for infection based on the McGeer criteria for infection in the long term care facility. Review of facility policy titled Medication Regimen Review, dated 11/28/16, revealed the consulting pharmacist was to perform a comprehensive review of each resident's medication regimen at least monthly. This was to include an evaluation of the resident's response to medication therapy to determine the resident maintained the highest practicable level of functioning while preventing or minimizing adverse consequences related to medication therapy. Recommendations were to be reported to the Director of Nursing, attending practitioner, the attending practitioner, the medical director and /or the administrator. The resident's drug regimen was to be free from unnecessary medications, which was any medication used in excessive dose, excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of any adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 20 of 20