Health inspection·September 19, 2019

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to follow their abuse policy to immediately report to the Administrator and investigate an incident of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Residents Affected - Few Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of plan of care updated 08/28/19 noted the resident had an activity of daily living self care deficit . Review of the medical record revealed no mention of Resident # 97 ever having a black eye. Review of a facility SRI, dated 08/21/19, revealed Resident #97 was noted to have a black and blue eye on the left side. The the facility was unable to determine the cause of the black and blue eye. The SRI was submitted as an injury of unknown origin. Interview on 09/16/19 at 3:14 P.M. with Resident #97 revealed he had never been abused by anyone at the facility. Interview on 09/18/19 at 9:30 A.M., the Director of Nursing (DON) stated on 08/21/19 Ombudsman #500 reported to her and the Administrator she had received a concern from Resident #97's family. Ombudsman #500 had reported the family had stated the resident had a black eye and the facility's staff did not know how it occurred. Review of SRI investigation revealed a written statement from State Tested Nursing Assistant (STNA) #300, dated 08/22/19, noted on 08/16/19 when he returned to work after some time off, he was getting Resident #97 up for the day when he noticed the resident had a black and blue left eye. When he asked the resident how it had happened, the resident replied he did not know. His eye was swollen and bruised as well. Review of a written statement by STNA #310, dated 08/22/19, documented she noticed a discolored area on Resident #97's face midway through the prior week. Resident #97 had been unsure of what happened. Review of an undated written statement by STNA #305 documented she noticed Resident #97 had a bruise to the right side of his face at 9:30 A.M. The statement noted Resident #97 didn't know how it happened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 2 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with the DON on 09/18/19 at 10:00 A.M. verified there was no date as to when STNA #305 saw the bruise to the resident's face and STNA #305 had identified the bruise to be on the right side instead of the reported left side. She verified she did not interview the STNA as to the date or the location of the bruise. The DON revealed she had not assessed Resident #97 on 08/21/19 upon receiving the report of the black eye. Resident #97 wasn't assessed until 08/26/19 and there was no bruising to his eyes. The DON indicated she did not assess or interview any other residents in the area concerning staff treatment. She verified she did not interview all staff members having contact with Resident #97 prior to the initial discovery of the injury. Interview with the Administrator on 09/18/19 at 10:30 A.M. verified he was made aware of the the incident on 08/21/19 when the Ombudsman notified the facility of the concern by Resident #97's family of the resident having a black eye. Interview on 09/19/19 at 10:00 P.M., Ombudsman #500 verified on 08/21/19 she received a call from Resident #97's family stating the resident had a black and blue eye for a week and the facility staff could not tell them what happened. Ombudsman #500 stated she observed Resident #97 on 08/21/19 and there was a faint black and blue mark under the resident's left eye. She stated she reported the concern and the black and blue mark to the DON and Administrator. She stated she was told the resident sleeps with his glasses on and leans to one side while he is sleeping. She stated during her interview with Resident #97 on 08/21/19 the resident denied sleeping with his glasses on. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 02/01/18, revealed the facility will consider factors including bruises as potential abuse. The policy noted if abuse is suspected all allegations will be immediately reported to the Administrator. The investigation shall include interviewing all persons involved, including any alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and provide complete and through documentation of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 3 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to report an injury of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of a facility SRI, dated 08/21/19, revealed Resident #97 was noted to have a black and blue eye on the left side. The the facility was unable to determine the cause of the black and blue eye. The SRI was submitted as an injury of unknown origin. Interview on 09/18/19 at 9:30 A.M., the Director of Nursing (DON) stated on 08/21/19 Ombudsman #500 reported to her and the Administrator she had received a concern from Resident #97's family. Ombudsman #500 had reported the family had stated the resident had a black eye and the facility's staff did not know how it occurred. Review of SRI investigation revealed a written statement from State Tested Nursing Assistant (STNA) #300, dated 08/22/19, noted on 08/16/19 when he returned to work after some time off, he was getting Resident #97 up for the day when he noticed the resident had a black and blue left eye. When he asked the resident how it had happened, the resident replied he did not know. His eye was swollen and bruised as well. Review of a written statement by STNA #310, dated 08/22/19, documented she noticed a discolored area on Resident #97's face midway through the prior week. Resident #97 had been unsure of what happened. Review of an undated written statement by STNA #305 documented she noticed Resident #97 had a bruise to the right side of his face at 9:30 A.M. The statement noted Resident #97 didn't know how it happened. Interview with the Administrator on 09/18/19 at 10:30 A.M. verified he was made aware of the the incident on 08/21/19 when the Ombudsman notified the facility of the concern by Resident #97's family of the resident having a black eye. Interview on 09/19/19 at 10:00 P.M., Ombudsman #500 verified on 08/21/19 she received a call from Resident #97's family stating the resident had a black and blue eye for a week and the facility staff could not tell them what happened. Ombudsman #500 stated she observed Resident #97 on 08/21/19 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 4 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete there was a faint black and blue mark under the resident's left eye. She stated she reported the concern and the black and blue mark to the DON and Administrator. She stated she was told the resident sleeps with his glasses on and leans to one side while he is sleeping. She stated during her interview with Resident #97 on 08/21/19 the resident denied sleeping with his glasses on. Review of the facility policy titled Abuse, Neglect and Exploitation, dated 02/01/18, revealed the facility will consider factors including bruises as potential abuse. The policy noted if abuse is suspected all allegations will be immediately reported to the Administrator. Event ID: Facility ID: 366102 If continuation sheet Page 5 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0610 Respond appropriately to all alleged violations. 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 Self-Reported Incident (SRI), staff and resident interviews, and facility policy review, the facility failed to investigate an incident of unknown origin for one resident (#97) identified in 12 SRI's reviewed. The facility census was 115. Residents Affected - Few Findings include: Review of the medical record revealed Resident #97 was admitted to the facility on [DATE]. Diagnoses included chronic partial fibrillation, chronic obstructive pulmonary disease, and major depressive disorder Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/28/19, revealed the resident had no cognitive deficits. His vision was adequate with the use of corrective lens. He required extensive assistance with bed mobility and transfers. He was unable to ambulate. The assessment revealed he had no current skin conditions. Review of the medical record revealed no mention of Resident # 97 ever having a black eye. Review of a facility SRI, dated 08/21/19, revealed Resident #97 was noted to have a black and blue eye on the left side. The the facility was unable to determine the cause of the black and blue eye. The SRI was submitted as an injury of unknown origin. Interview on 09/16/19 at 3:14 P.M. with Resident #97 revealed he had never been abused by anyone at the facility. Interview on 09/18/19 at 9:30 A.M., the Director of Nursing (DON) stated on 08/21/19 Ombudsman #500 reported to her and the Administrator she had received a concern from Resident #97's family. Ombudsman #500 had reported the family had stated the resident had a black eye and the facility's staff did not know how it occurred. Review of SRI investigation revealed a written statement from State Tested Nursing Assistant (STNA) #300, dated 08/22/19, noted on 08/16/19 when he returned to work after some time off, he was getting Resident #97 up for the day when he noticed the resident had a black and blue left eye. When he asked the resident how it had happened, the resident replied he did not know. His eye was swollen and bruised as well. Review of a written statement by STNA #310, dated 08/22/19, documented she noticed a discolored area on Resident #97's face midway through the prior week. Resident #97 had been unsure of what happened. Review of an undated written statement by STNA #305 documented she noticed Resident #97 had a bruise to the right side of his face at 9:30 A.M. The statement noted Resident #97 didn't know how it happened. Interview with the DON on 09/18/19 at 10:00 A.M. verified there was no date as to when STNA #305 saw the bruise to the resident's face and STNA #305 had identified the bruise to be on the right side instead of the reported left side. She verified she did not interview the STNA as to the date or the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 6 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0610 Level of Harm - Minimal harm or potential for actual harm location of the bruise. The DON revealed she had not assessed Resident #97 on 08/21/19 upon receiving the report of the black eye. Resident #97 wasn't assessed until 08/26/19 and there was no bruising to his eyes. The DON indicated she did not assess or interview any other residents in the area concerning staff treatment. She verified she did not interview all staff members having contact with Resident #97 prior to the initial discovery of the injury. Residents Affected - Few Review of the facility policy titled Abuse, Neglect and Exploitation, dated 02/01/18, revealed the facility will consider factors including bruises as potential abuse. The policy noted if abuse is suspected all allegations will be immediately reported to the Administrator. The investigation shall include interviewing all persons involved, including any alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and provide complete and through documentation of the investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 7 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 - Some 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 and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected five (#9, #36, #49, #100 and #112) of five residents reviewed for hospitalizations. The facility census was 115. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sepsis, difficulty walking, unspecified ileus, pressure ulcer - sacral stage four, acute kidney failure, diabetes mellitus, non-inflammatory vaginal disorder, gastrostomy, dysphagia, moderate protein calorie malnutrition, gait and mobility abnormalities, hyperlipidemia, hyperosmolality, hypernatremia, hypokalemia, affective mood disorder and unspecified intellectual disabilities. Review of the medical record for Resident #9 revealed the resident was transferred to the hospital on [DATE] at 3:51 P.M. Resident #9 returned to the facility on [DATE] at 3:30 P.M. Resident #9's medical record revealed it to be silent for the resident representative being notified in writing of the residents transfer to the hospital. .2. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included liver contusion, anemia, obstructive and reflux uropathy, cystic liver disease, benign prostatic hyperplasia, acute cystitis with hematuria, sepsis, dysphagia, chronic embolism and thrombosis of deep vein of lower extremity, left shoulder pain, left hip pain, difficulty walking, pulmonary embolism, cerebral infarction, diverticulum of esophagus, protein calorie malnutrition, hereditary motor and sensory neuropathy, hypertension, muscle weakness, gait and mobility abnormalities, dysphagia and a gastrostomy. Review of the medical record for Resident #49 revealed the resident was transferred to the hospital on [DATE] at 8:30 P.M. and again on 07/07/19 at 11:15 P.M. Resident #49 returned to the facility on [DATE] at 7:15 P.M. and returned from the second hospitalization on 07/12/19 at 6:58 P.M. Resident #49's medical record revealed it to be silent for the resident representative being notified in writing of the residents transfers to the hospital. 3. Review of the medical record for Resident #112 revealed an admission date of 04/06/19. Diagnoses included acute kidney failure, epididymitis, methicillin resistant staphylococcus aureus, gait and mobility abnormalities, obstructive and reflux uropathy, difficulty walking, acute respiratory failure with hypoxia, hypertensive heart disease, pneumonia, urinary tract infection, shortness of breath, type two diabetes mellitus, morbid obesity due to excess calories, hypertension, hyperlipidemia, acute ischemic heart disease, peripheral vascular disease, muscle weakness, urinary retention, generalized edema and congestive heart failure. Review of the medical record revealed Resident #112 was transferred to the hospital on [DATE] at 5:04 P.M., on 06/16/19 at 10:48 A.M. and on 08/16/19 at 3:28 P.M. Resident #112's medical record revealed it to be silent for the resident representative being notified in writing of the residents transfers to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 8 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 - Some Further review of Resident #112's medical record revealed the resident returned to the facility on [DATE] at 2:28 P.M., on 06/24/19 at 8:20 P.M. and on 08/23/19 at 12:30 A.M. 4. Review of Resident #100's medical record revealed an admission date of of 01/28/19. Diagnoses included diabetes, pressure ulcer right heel, muscle weakness, chronic kidney disease, and hypertension. Further review revealed the resident had a hospitalization from 09/12/19 through 09/15/19. Review of Resident #100's Minimum Data Set (MD) dated 09/12/19 revealed a discharge assessment was completed. Review of Resident #100's nurse's notes revealed the resident was sent to the hospital on [DATE]. Resident #100's medical record revealed it to be silent for the resident representative being notified in writing of the residents transfers to the hospital. 5. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE]. Diagnoses included heart failure, diabetes, severe protein calorie malnutrition, psychotic disorder with hallucinations, Alzheimer's disease, major depression. Review of the medical record reveled Resident #36 was admitted to the hospital on [DATE] for congestive heart failure and acute kidney injury and was readmitted to the facility on [DATE]. Resident #36 medical record revealed it to be silent for the resident representative being notified in writing of the residents transfer to the hospital. Interview on 09/18/19 at 1:50 P.M. with the Director of Nursing confirmed the facility was not providing written documentation to the resident representative in a language they understand for each hospital transfer. This included Residents #9, #36, #49, #100 and #112. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 9 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to issue written notice of the reasoning for transfer to the hospital to the resident and/or resident representative. This affected five (#9, #36, #49, #100 and #112) of five residents reviewed for hospitalizations. The facility census was 115. Findings include: 1. Review of Resident #9's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sepsis, difficulty walking, unspecified ileus, pressure ulcer - sacral stage four, acute kidney failure, diabetes mellitus, non-inflammatory vaginal disorder, gastrostomy, dysphagia, moderate protein calorie malnutrition, gait and mobility abnormalities, hyperlipidemia, hyperosmolality, hypernatremia, hypokalemia, affective mood disorder and unspecified intellectual disabilities. Review of the medical record for Resident #9 revealed the resident was transferred to the hospital on [DATE] at 3:51 P.M. Resident #9 returned to the facility on [DATE] at 3:30 P.M. Resident #9's medical record revealed it to be silent for the resident representative being notified in writing of the facility's bed hold policy. 2. Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included liver contusion, anemia, obstructive and reflux uropathy, cystic liver disease, benign prostatic hyperplasia, acute cystitis with hematuria, sepsis, dysphagia, chronic embolism and thrombosis of deep vein of lower extremity, left shoulder pain, left hip pain, difficulty walking, pulmonary embolism, cerebral infarction, diverticulum of esophagus, protein calorie malnutrition, hereditary motor and sensory neuropathy, hypertension, muscle weakness, gait and mobility abnormalities, dysphagia and a gastrostomy. Review of the medical record for Resident #49 revealed the resident was transferred to the hospital on [DATE] at 8:30 P.M. and again on 07/07/19 at 11:15 P.M. Resident #49 returned to the facility on [DATE] at 7:15 P.M. and returned from the second hospitalization on 07/12/19 at 6:58 P.M. Resident #49's medical record revealed it to be silent for the resident representative being notified in writing of the facility's bed hold policy. 3. Review of the medical record for Resident #112 revealed an admission date of 04/06/19. Diagnoses included acute kidney failure, epididymitis, methicillin resistant staphylococcus aureus, gait and mobility abnormalities, obstructive and reflux uropathy, difficulty walking, acute respiratory failure with hypoxia, hypertensive heart disease, pneumonia, urinary tract infection, shortness of breath, type two diabetes mellitus, morbid obesity due to excess calories, hypertension, hyperlipidemia, acute ischemic heart disease, peripheral vascular disease, muscle weakness, urinary retention, generalized edema and congestive heart failure. Review of the medical record revealed Resident #112 had three admissions to the hospital. The record indicated Resident #112 was transferred to the hospital on [DATE] at 5:04 P.M., on 06/16/19 at 10:48 A.M. and on 08/16/19 at 3:28 P.M. Resident #12's medical record revealed it to be silent for the resident representative being notified in writing of the facility's bed hold policy. Resident #112's medical record revealed the resident returned to the facility on [DATE] at 2:28 P.M., on 06/24/19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 10 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 at 8:20 P.M. and on 08/23/19 at 12:30 A.M. Level of Harm - Minimal harm or potential for actual harm 4. Review of Resident #100's medical record revealed an admission date of of 01/28/19. Diagnoses included diabetes, pressure ulcer right heel, muscle weakness, chronic kidney disease, and hypertension. Further review revealed the resident had a hospitalization from 09/12/19 through 09/15/19. Residents Affected - Some Review of Resident #100's Minimum Data Set (MD) assessment, dated 09/12/19, revealed a discharge assessment was completed. Review of Resident #100's nurse's notes revealed the resident was sent to the hospital on [DATE]. Continued review of Resident #100's medical record revealed it to be silent for the resident representative being notified in writing of the facility's bed hold policy. 5. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, diabetes, severe protein calorie malnutrition, psychotic disorder with hallucinations, Alzheimer's disease, major depression. Review of the medical record reveled Resident #36 was admitted to the hospital on [DATE] for congestive heart failure and acute kidney injury and was readmitted to the facility on [DATE]. Continued review of Resident #36's medical record revealed it to be silent for the resident representative being notified in writing of the facility's bed hold policy. Interview on 09/18/19 at 1:50 P.M. with the Director of Nursing confirmed the facility was not notifying the resident representative of the bed hold policy when residents were transferred to the hospital. The Director of Nursing indicated this is only done upon admission to the facility. She verified Residents #9, #36, #49, #100 and #112 had not been given the bed hold policy when they were transferred to the hospital. Review of a facility policy titled Bed Hold Notice Upon Transfer, dated 02/01/18, revealed at the time of transfer for hospitalization or therapeutic leave, the Center will provide to the resident and/or resident representative written notice which specifies the duration of the bed hold policy. The policy further stipulates that in the event of an emergency transfer of a resident, the Center will provide within 24 hours, a written notice of the Center's bed hold policies as stipulated in each states plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 11 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and facility policy review the facility failed to complete a discharge summary for one (#121) of one resident reviewed for discharge summary. The facility census was 115. Findings include: Review of the medical record revealed Resident #121 was admitted to the facility on [DATE]. Diagnoses included of aftercare following surgery for neoplasm, hypertension, hemiplegia and anemia. Resident #121 was discharged from the facility on 08/10/19. Review of the physician order dated 08/10/19 revealed to discharge the resident to home per hospice. Review of the nurse progress notes revealed on 08/14/19 at 11:19 A.M. social worker was not able to assess resident. He was admitted on hospice and discharged home over the weekend with family. A note dated 08/12/19 at 9:49 A.M. and titled Discharge Summary included that Resident #121 was admitted to the facility on [DATE]. He was discharged on 08/10/19 prior to the activity assessment being completed. Further review of the nurse progress notes revealed no other information or discharge summary was present. Review of the medical record contained no discharge summary for Resident #121's care at the time of discharge. Interview with Director of Nursing (DON) on 09/19/19 at 11:18 A.M. verified there was no discharge summary for Resident #121. DON stated Resident #121's family wished for him to be discharged quickly and the discharge paper work was not completed. The only discharge papers provided upon his discharge were the medications and physician orders. DON verified Resident #121 and his family were not provided with a summary which included a recapitulation of his stay, a final summary of his status, a post discharge plan of care or discharge services. Review of the facility policy titled Discharge Summary and Plan of Care, dated 03/01/18, revealed when the facility anticipated the discharge of a resident, a discharge plan summary should be developed. Anticipate means that the discharge was not an emergency discharge(an acute condition)or due to the resident's death. Upon discharge of a resident other than in emergency or death a discharge summary is provided to the receiving care provider. The discharge summary should include: 1) A recapitulation of the resident's stay that includes but not limited to diagnoses, course of illness/treatment or therapy and pertinent lab, radiology and consultation results. 2) A final summary of the resident's status at the time of discharge that is available for release to authorized persons and agencies, with the consent of the resident/resident's representative. 3) Reconciliation of all pre-discharge medications with the resident's post discharge medications with the resident's post discharge medications to include prescription and over the counter medications. 4) a post discharge plan of care developed with the resident/resident representative. The plan must indicate where the individual plans to reside and any follow up care and post discharge medical and non-medical services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 12 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to provide ongoing assessment and monitoring of non-pressure wounds and failed to complete physician ordered treatments to the wounds. This affected one (#320) of nine residents identified by the facility with non-pressure wounds. The facility census was 115. Residents Affected - Few Findings include: Review of the medical record revealed Resident #320 was admitted to the facility on [DATE]. Diagnoses included non-pressure chronic ulcer of the left lower leg with fat layer exposed to the left calf, left foot and right leg, morbid (severe) obesity, diabetes, cellulitis of the left lower limb, chronic embolism and thrombosis of the right popliteal vein, peripheral vascular disease (PVD), and methicillin-resistant staphylococcus aureus (MRSA). Review of the admission Minimum Data Set (MDS) assessment, completed 09/12/19, revealed Resident #320 was cognitively intact. Resident #320 had no pressure wounds. Resident #320 had four venous ulcers and a diabetic foot wound on the assessment. Review of the Skin Observation Tool dated 09/01/19 with a description of Admission identified wounds present at the time of admission included nine identified skin conditions: Area #1 was right outer ankle cellulitis measuring length of 9 centimeters (cm), width of 9 cm, and no depth. Area #2 was the front of the left lower leg cellulitis measuring 9 cm long, 9 cm wide, and no depth. Area #3 was the front of the left lower leg of a vascular source measuring 8 cm long by 4 cm wide by 1 cm deep. Area #4 as the rear left lower leg cellulitus measuring 28 cm long by 28 cm wide with no depth. Area #5 was the left lower rear leg of vascular source measuring 10 cm long by 7 cm wide, by no depth. Area #6 included the left toes identified as vascular in source measuring 9 cm long by 9 cm wide by 1 cm deep. Area #7 was a vascular ulcer to the right lower leg front measuring 5 cm long by 4.5 cm wide by 1 cm deep. There was no assessment of the area which included drainage, odor, infection, wound bed appearance, or periwound condition. The record contained no further specific assessments of these identified areas. Review of the physician order dated 09/06/19, discontinued 09/10/19, was wash both bilateral lower legs with soap (Baby Shampoo) and water. Irrigate ulcers with Dakin's 0.25% solution. Then apply Medi Honey to leg wounds, cover with gauze wrap, kerlix and cover with ace bandages every day shift. Review of the Treatment Administration Record (TAR) revealed the ordered treatment was not completed on 09/07/19 and 09/10/19. Review of the Skin Observation Tool dated 09/08/19 with a description of Other revealed the assessment included four identified skin conditions: Area #1 was identified as a vascular area to the right front lower leg measuring 0.8 cm in length by 4 cm wide and 0.1 cm deep. Area #2 was a vascular are to the left heel measuring 2.5 cm deep by 3 cm wide by 0.1 cm deep. Area #3 was a vascular are to the left lower rear leg measuring 10 cm long by 7.5 cm wide by 0.2 cm deep. Area #4 was a vascular are to the left lower rear leg measuring 11.5 cm long by 9 cm wide by 0.2 cm deep. There was no assessment of the area which included drainage, odor, infection, wound bed appearance, or periwound condition. There is no indication as to wether these were the same areas as those identified on 09/08/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 13 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the wound clinic notes dated 09/10/19 revealed Resident #320 wounds were assessed and included: Area #1 to the pretibial, right; lower anterior leg measuring 0.8 cm in length by 4 cm wide and 0.1 cm deep. Area #2 was the left anterior dorsal foot measuring 10 cm long by 7.5 cm wide by 0.2 cm deep. Area #3 was the pretibial, anterior, left lower leg measuring 2.5 cm long by 3 cm wide by 0.1 cm deep. Area #4 was the left tibial, posterior, lower leg measuring 11.5 cm long by 9 cm wide by 0.2 cm deep. The wound clinic assessments included full assessments of the leg wounds with measurements, identification of the wound type, wound appearance, amount of drainage and description of the drainage, odor and peri-wound assessment. There were no further assessments of the areas in the medical record. Review of Resident #320's physician orders dated 09/10/19 was wash both bilateral lower legs with soap (Baby Shampoo) and water. Irrigate ulcers with Dakin's full-strength solution then cover with kerlix wrap, and then with ace bandages every day and night shift. Review of Resident #320's TAR revealed the treatment was not completed on 09/13/19 or 09/14/19 at night or on 09/15/19 in the morning. Observation of Resident #320's dressing change with Licensed Practical Nurse (LPN) #501 on 09/19/19 at 12:45 P.M. revealed one open area at the left anterior lower leg approximately 0.8 cm by 1 cm with no depth, three open areas on the left lower posterior leg measuring 3.5 cm by 1 cm with no depth; 1.5 cm by 1 cm with no depth and 3.5 cm by 5 cm with no depth; one open area at the left anterior foot measuring 5 cm by 2.5 cm and no depth; one open area at the right anterior lower leg 1 cm by 1.5 cm and no depth with a cluster of small open areas around the anterior wound. LPN #501 did not measure the wounds but estimated the measurements and verified Resident #320 had five wounds on his leg and foot and one wound on his right leg. However, LPN #501 stated she believed the three areas on Resident #320's left posterior leg had originally been one wound and was improved. Interview with Director of Nursing (DON) on 09/18/19 at 4:12 P.M. she verified Resident #320's were not assessed completely until the wound clinic on 09/10/19 and there were no assessments after. The DON verified the facility assessments did not match each other. The DON verified the treatment had not been completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 14 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 and staff interview, the facility failed to provide ongoing monitoring to validate the continued use of a statin medication for one (#63) of five residents reviewed for unnecessary medications. The facility census was 115. Residents Affected - Few Findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, depression, diabetes, dementia, hypertension, anxiety and hyperlipidemia. Review of the physician orders revealed Atorvastatin Calcium Tablet 40 milligrams (mg) give one tablet by mouth at bedtime related to hyperlipidemia dated 06/25/19. Review of the laboratory (lab) results from 09/01/18 to 09/19/19 revealed Resident #63 had no lab test completed for cholesterol. Interview with Director of Nursing (DON) on 09/19/19 at 10:15 A.M. verified Resident #63 was prescribed Atorvastatin (a statin medication for high cholesterol levels). The DON verified Resident #63 did not have any lab testing for the continued use or need for the statin. DON stated Resident #63 had not been lab tested for cholesterol levels since 2017. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 15 of 16 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 366102 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Francis Senior Ministries 182 St Francis Ave Tiffin, OH 44883 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on review of the facility's Quality Assessment and Assurance (QAA) meeting sign in documents and staff interview, the facility failed to ensure the medical director attended the QAA meetings on a quarterly basis. This had the potential to affect all 115 residents in the facility. Residents Affected - Many Finding include : Review of the QAA quarterly sign in sheets dated 10/18/18, 01/24/19, and 07/17/19 revealed the Medical Director did not attend. Interview on 09/19/19 at 2:30 P.M. the Director of Nursing verified the Medical Director did no sign in as attending the quarterly QAA meeting on 10/18/18, 01/24/19, and 07/17/19 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366102 If continuation sheet Page 16 of 16