Health inspection·March 14, 2019

F 0604 Level of Harm - Minimal harm or potential for actual harm after being cued multiple times she was able to slightly lift up the plastic clip to her seat belt setting off the alarm. Resident #64's seat belt was remained fastened with the Velcro. RN #124 verified Resident #64 was able to lift the plastic clip on her seat belt after being cued multiple times, however the seat belt remained fastened with the Velcro. RN #124 revealed the resident became agitated at times when attempting to remove the seat belt. Residents Affected - Few Review of the facility's Physical Restraints policy dated 01/08/12 revealed physical restraints to be any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's own body. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 2 of 5 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 366143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adams County Manor 10856 State Route 41 West Union, OH 45693 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 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, staff interview, and facility policy review, the facility failed to implement their abuse policy when they failed to submit a self-reported incident (SRI) to the state agency regarding a resident to resident physical abuse, and further failed to ensure a resident was free from resident to resident physical abuse. This affected one resident (#12) of one resident reviewed for abuse. The facility census was 73. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of Resident #12's annual Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #12's progress note written by Registered Nurse (RN) #124 dated 12/19/18 revealed Resident #12 said a man came in and grabbed her wrist and knocked her stuff off of her door. Resident #12 was noted with a small skin tear and a bruise. Both residents were separated. Resident #12 was ordered a treatment for her wrist. 2. Medical record review revealed Resident #220 was admitted to the facility on [DATE] with the following diagnoses; transient cerebral ischemia attack (stroke), unspecified psychosis not due to substance or known physiological condition, Alzheimer's disease, and major depressive disorder. Resident #220 passed away at the facility on 01/20/19. Review of the resident MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #220's progress note written by RN #124 dated 12/19/18 revealed a State Tested Nurse Aide (STNA) reported Resident #12 said Resident #220 came in her room, knocked decorations off her door and grabbed her wrist causing a skin tear with a small bruise. Both residents were separated and placed on 15 minute checks. Review of the Activities Director (AD) #14's statement dated 12/19/18 revealed the AD was walking down the hallway and witnessed Resident #220 at Resident #12's doorway pulling at her decorations. Resident #12 approached Resident #220 at the same time and Resident #220 reached out and grabbed Resident #12's wrist. AD #14 intervened and redirected Resident #220 away from the doorway. Interview with the Director of Nursing (DON) on 03/13/19 at 12:57 P.M., verified Resident #220 grabbed Resident #12 causing a bruise and an skin tear on 12/19/18. The DON revealed she investigated the incident and found Resident #220 was knocking down Resident #12's decorations and grabbed Resident #12's arm and his finger nail caught her arm leaving a skin tear. The DON confirmed a SRI was not completed and submitted regarding the resident to resident physical abuse between Resident #12 and Resident #220. Review of the facility's Abuse and Neglect policy dated November 2018 revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, or pain or mental anguish. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 3 of 5 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 366143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adams County Manor 10856 State Route 41 West Union, OH 45693 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 immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse or do not result in serious bodily injury. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 4 of 5 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 366143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adams County Manor 10856 State Route 41 West Union, OH 45693 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, staff interview, and facility policy review, the facility failed to report and submit a self-reported incident (SRI) of resident to resident physical abuse to the state agency within 24 hours. This affected one resident (#12) of one resident reviewed for abuse. The facility census was 73. Findings include: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of Resident #12's annual Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #12's progress note written by Registered Nurse (RN) #124 dated 12/19/18 revealed Resident #12 said a man came in and grabbed her wrist and knocked her stuff off of her door. Resident #12 was noted with a small skin tear and a bruise. Both residents were separated. Resident #12 was ordered a treatment for her wrist. 2. Medical record review revealed Resident #220 was admitted to the facility on [DATE] with the following diagnoses; transient cerebral ischemia attack (stroke), unspecified psychosis not due to substance or known physiological condition, Alzheimer's disease, and major depressive disorder. Resident #220 passed away at the facility on 01/20/19. Review of the resident MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #220's progress note written by RN #124 dated 12/19/18 revealed a State Tested Nurse Aide (STNA) reported Resident #12 said Resident #220 came in her room, knocked decorations off her door and grabbed her wrist causing a skin tear with a small bruise. Both residents were separated and placed on 15 minute checks. Review of the Activities Director (AD) #14's statement dated 12/19/18 revealed the AD was walking down the hallway and witnessed Resident #220 at Resident #12's doorway pulling at her decorations. Resident #12 approached Resident #220 at the same time and Resident #220 reached out and grabbed Resident #12's wrist. AD #14 intervened and redirected Resident #220 away from the doorway. Interview with the Director of Nursing (DON) on 03/13/19 at 12:57 P.M., verified Resident #220 grabbed Resident #12 causing a bruise and an skin tear on 12/19/18. The DON revealed she investigated the incident and found Resident #220 was knocking down Resident #12's decorations and grabbed Resident #12's arm and his finger nail caught her arm leaving a skin tear. The DON confirmed a SRI was not completed regarding the resident to resident physical abuse between Resident #12 and Resident #220. Review of the facility's Abuse and Neglect policy dated November 2018 revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse or do not result in serious bodily injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 5 of 5