Health inspection·August 31, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a dependent resident received adequate assistance with shaving. This affected one (#13) of one residents reviewed for activities of daily living. The facility census was 51. Residents Affected - Few Findings include: Review of Resident #13's medical record revealed an admission date of 07/22/21. Diagnoses included dementia, hypertension, atherosclerotic heart disease, anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was severely cognitively impaired and required extensive assistance with personal hygiene. Review of the plan of care initiated 08/13/21 revealed Resident #13 required assistance with activities of daily living (ADLs) due to physical limitations secondary to dementia and anxiety. Interventions included to set up supplies needed to assist with completion of ADLs, provide needed assistance of one staff member for proper completion of ADLs, encourage the resident to do as much as possible for herself, and give simple direct steps and allow ample time to complete the task at hand. Observations on 08/29/23 at 8:12 A.M. and on 08/30/23 at 8:05 A.M. of Resident #13 revealed the resident had several long hairs on her chin, approximately one-quarter inch in length. Interview on 08/30/23 at 9:26 A.M. with State Tested Nurse Aide (STNA) #504 stated Resident #13 required staff assistance with hygiene and grooming. STNA #504 stated shaving was typically done on shower days and she assisted Resident #13 with a shower on 08/29/23. STNA #504 stated she did not shave residents who did not have an electric razor because she was afraid of disposable razors. STNA #504 verified the hair growth on Resident #13's chin and confirmed she did not assist the resident with shaving during her shower on 08/29/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 2 of 6 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 08/31/2023 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide treatment for pressure ulcers per physician order. This affected one (#7) of one residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 51. Residents Affected - Few Findings include: Review of Resident #7's medical record revealed an admission date of 05/26/21. Diagnoses included atherosclerosis of native arteries of extremities, hypotension, atrial fibrillation, type II diabetes chronic kidney disease, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, was at risk for pressure ulcers, and had one stage II pressure ulcer (partial-thickness skin loss with exposed dermis). Review of the plan of care dated 06/07/21 revealed Resident #7 was at risk for skin breakdown. Interventions included wound treatment per facility protocol or wound care. Review of a wound care note dated 07/03/23 revealed Resident #7 had a stage II pressure wound to the coccyx which was acquired on 05/11/23. Additional review of wound care notes dated 07/10/23, 07/17/23, 07/24/23, and 08/01/23 revealed no worsening of the wound, and Resident #7 refused to lay down during the day to reduce pressure. Review of an assessment used to predict pressure ulcer development dated 08/12/23 revealed Resident #7 was at moderate risk for pressure sores. Review of physician orders dated 06/20/23 revealed Resident #7 was ordered to cleanse the sacral area with normal saline, pat dry, pack the wound with a thin strip of Mesalt, cover with Allevyn dressing, and change daily and as needed. Review of Resident #7's treatment administration record (TAR) for July 2023 revealed sacral treatments were not documented as provided on 07/04/23, 07/06/23, 07/11/23, 07/13/23, 07/18/23, 07/19/23, 07/20/23, and 07/22/23. Interview on 08/29/23 at 3:58 P.M. with the Director of Nursing (DON) verified the facility had no evidence Resident #7's wound treatments were administered as ordered by the physician on 07/04/23, 07/06/23, 07/11/23, 07/13/23, 07/18/23, 07/19/23, 07/20/23, and 07/22/23. Interview on 08/30/23 at 8:59 A.M. with Licensed Practical Nurse (LPN) #505 stated she was the treatment nurse. LPN #505 stated while Resident #7 was not always compliant with repositioning to relieve pressure, the resident was compliant with wound treatments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 3 of 6 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 08/31/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident receiving supplemental oxygen therapy had a physician order for use. This affected one (#301) of residents reviewed for oxygen therapy. The facility identified nine residents that use supplemental oxygen. The facility census was 51. Residents Affected - Few Findings include: Review of the medical record for Resident #301 revealed an admission date of 08/23/23 with diagnoses of heart failure and atrial fibrillation. Review of an initial assessment dated [DATE] revealed the resident was alert and oriented to person, place, and time, and was noted to have supplemental oxygen at two liters per minute by way of nasal cannula. Review of Resident #301's current physician orders for August 2023 revealed there were not any orders for supplemental oxygen therapy. Observation on 08/28/23 at 3:26 P.M. revealed Resident #301 was resting in bed after lunch and therapy with supplemental oxygen on at two liters per minute via nasal cannula. Interview on 08/28/23 at 3:26 P.M. with Resident #301 stated she was on oxygen at home only in the afternoon and during the night. Observation on 08/29/23 at 7:45 A.M. revealed Resident #301 was resting in bed with supplemental oxygen in place via nasal cannula at two liters per minute. Observation on 08/31/23 at 8:04 A.M. revealed Resident #301 was sitting in her recliner eating breakfast with supplemental oxygen on via nasal cannula at two liters per minute. Interview on 08/31/23 at 8:05 A.M. with Registered Nurse (RN) #508 verified Resident #301 was receiving supplemental oxygen by nasal cannula at two liters per minutes, and verified the medical record for Resident #301 contained no orders for supplemental oxygen therapy. Review of an undated facility policy titled, Oxygen Use/Administration, revealed oxygen must be prescribed by a physician, and a complete order must be obtained to include liter flow per minute, titration instructions, and type of delivery device (nasal cannula, simple mask). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 4 of 6 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 08/31/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, pharmacy staff interview, and review of a facility policy, the facility failed to ensure medications were administered per physician order. This affected one (#39) of three residents reviewed for medication administration. The facility census was 51. Findings include: Review of Resident #39's medical record revealed an admission date of 01/31/23. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, osteoarthritis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. Review of the plan of care initiated 02/20/23 revealed Resident #39 was at risk for shortness of breath related to COPD. Interventions included to administer medications as ordered and monitor for adverse side effects. Review of a current physician order dated 07/13/23 revealed Resident #39 was ordered the combination inhaled medication to treat COPD Breztri Aerosphere to receive two puffs orally two times a day. Review of Resident #39's medication administration record (MAR) from 08/01/23 through 08/30/23 revealed Breztri Aerosphere was documentated on 08/07/23 at the evening dose, on 08/08/23 at the morning dose, on 08/09/23 at the evening dose, on 08/11/23 at the evening dose, on 08/12/23 at the morning dose, on 08/28/23 at the evening dose, and on 08/29/23 at the morning dose with the MAR code of 9. Further review of the MAR revealed the code 9 indicated the medication was unavailable. Review of Resident #39's nursing progress notes related to administration of Breztri Aerosphere revealed on 08/07/23 the facility was waiting on pharmacy, on 08/08/23 the medication was on order, on 08/09/23 the medication was not available from pharmacy, on 08/11/23 the medication was not available, on 08/12/23 the medication was on order, and on 08/28/23 the medication was not available pharmacy was called. Interview on 08/28/23 at 12:27 P.M., with Resident #39 stated he had not received his Breztri Aerosphere inhaler as physician ordered. Resident #39 stated nursing staff told him it had been ordered, but the pharmacy had not delivered it. Resident #39 stated he was concerned he did not have his medication like he was supposed to because he had blood clots in his lungs in the past. Interview on 08/30/23 at 3:46 P.M., with the Director of Nursing (DON) verified Resident #39 did not receive Breztri Aerosphere as ordered on 08/08/23, 08/09/23, 08/11/23, 08/12/23, and 08/28/23. The DON stated she became aware on 08/28/23 the inhaler was not available, and it was believed it was accidentally thrown away. The DON stated the medication was reordered on 08/28/23, but it was too early to refill the medication. As a result, the DON authorized the refill with the facility paying for the cost of the medication. The DON verified the medication should have been in the facility for administration, and Resident #39 did not receive the inhaler as ordered. Interview on 08/30/23 at 3:55 P.M., with Pharmacy Order Entry Technician (POET) #507 confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 5 of 6 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 08/31/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #39's Breztri Aerosphere was filled and delivered to the facility on [DATE] and 08/13/23. On 08/28/23, the pharmacy received a refill request but since each order was a 30-day supply, it was too soon to fill the order request. POET #507 confirmed the facility authorized payment and the medication was delivered on 08/29/23. Review of an undated facility policy titled, Medication Administration Policy, revealed medications shall be administered only upon the order of a physician or other Licensed Independent Practitioner who is authorized to provide care to the resident. If a medication is not available during the process, the nurse indicates this in the electronic medication administration record (EMAR). Additionally, a note is documented in the EMAR by the nurse detailing the communication to the pharmacy regarding the missing medication. This deficiency represents non-compliance investigated under Complaint Number OH00131350. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366097 If continuation sheet Page 6 of 6