Health inspection·July 1, 2021

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on record review and staff interview, the facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. This affected one (Resident #13) of 18 residents reviewed for accurate MDS assessments. The facility census was 64 residents. Residents Affected - Few Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/15/19. Diagnoses included dementia and transient cerebral ischemic attack. Review of the progress notes revealed the resident had falls on 03/04/21, 11/22/20, and 11/07/20. Review of the Minimum Data Set (MDS) assessments revealed a quarterly assessment was completed on 04/05/21, an annual assessment was completed on 02/11/21, and a quarterly assessment on 11/18/20. No additional MDS assessments were completed between 11/18/20 and 04/05/21. Subsequent review of the MDS assessments, dated 04/05/21 and 02/11/21, revealed section J1800 was negative for any falls since the prior assessment. Interview on 06/30/21 at 2:38 P.M. with Licensed Practical Nurse (LPN) #114 verified the MDS assessments for Resident #13, dated 04/05/21 and 02/11/21, were coded incorrectly and should have indicated there was a fall. 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 07/01/2021 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 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 record review, observations, and staff interviews, the facility failed to obtain a physician order for the use of oxygen, failed to administer oxygen as physician ordered, and failed to properly label the oxygen tubing during continuous use. This affected three residents (Resident #27, #44, and #215) of 23 residents receiving oxygen therapy. The facility census was 64. Residents Affected - Few Findings include: 1. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and congestive heart failure. Review of the Minimum Data Set assessment, dated 05/05/21, revealed the resident was rarely/never understood. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula. Observation of Resident #27 on 06/28/21 at 2:38 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing was still not labeled or dated. During this observation, Registered Nurse (RN) #212 verified the oxygen was running at three liters per minute and tubing was unlabeled or dated. The RN explained a contracted provider supplies the oxygen and they change out the tubing weekly, and they do not label or date the tubing. 2. Record review for Resident #215 on 06/29/21 at 1:58 P.M. revealed the resident was admitted to the facility on [DATE]. Diagnoses included asthma and emphysema. Review of the MDS assessment, dated 06/19/21, revealed the resident had intact cognition. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order for the use of oxygen at two liters via nasal cannula. Observation of Resident #215 on 06/28/21 at 3:22 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing still not labeled or dated. During the observation, RN #212 verified the oxygen was running at three liters per minute and the tubing was unlabeled or dated. On 06/30/21 at 2:40 P.M., an interview with the Director of Nursing (DON) on 06/30/21 at 2:40 P.M. verified Resident #27 and #215 did not have an active order for oxygen in place until it was obtained on 06/29/21. The DON verified the physician orders were for two liters, not three liters for Resident #27 and #215. 3. Review of the medical record for Resident #44 revealed an admission date of 01/09/13. Diagnoses included chronic obstructive pulmonary disease (COPD) and cerebral infarction. Review of the quarterly MDS assessment, dated 06/15/21, revealed the resident had impaired cognition. Review of the physician's orders revealed order on 08/20/20 for oxygen at two liters per minute as needed per nasal cannula six to eight per day and an order on 09/26/17 for one dose duoneb solution (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 07/01/2021 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 0695 0.5-2.5 (3.0) milligrams/3.0 milliliter solution every four hours as needed. Level of Harm - Minimal harm or potential for actual harm Review of the treatment administration record (TAR) revealed RN #139 signed off the oxygen as administered on 06/28/21 and 06/29/21. Residents Affected - Few Observations on 06/28/21 at 9:42 A.M. and 11:43 A.M, and on 06/29/21 at 3:00 P.M., and 4:08 P.M. revealed no oxygen concentrator nor oxygen tank in Resident #44's room. Observation on 06/29/21 at 3:00 P.M. revealed a nebulizer placed on Resident #44's bedside table. The tubing did not contain any date to indicate when it was last replaced. Interview on 06/29/21 at 4:08 P.M. with RN #139 verified there was no there was no date on the nebulizer tubing nor were there oxygen concentrator or tanks in Resident #44's room. The RN further stated Resident #44 had not received oxygen anytime recently. RN #139 verified the MAR had been signed off indicating the oxygen was administered when the oxygen had not been administered. 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 07/01/2021 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and staff interview, the facility failed to ensure the resident's call lights were functioning. This affected three (Resident #09, #16 and #18) of 24 residents reviewed for call lights. The facility census was 64 residents. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #09 revealed an admission date of 03/31/21. Diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, muscle weakness, and bipolar disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/23/21, revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the medical record for Resident #18 revealed an admission date of 09/17/20. Diagnoses included cerebrovascular disease, acute ischemic heart disease, dementia with behavioral disturbance, and cerebral infarction (stroke). Review of the comprehensive MDS assessment, dated 04/14/21, revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toileting. Observation on 06/28/21 at 11:28 A.M. revealed Resident #09's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Observation on 06/28/21 at 11:29 A.M. revealed Resident #18's (Resident #09's roommate) call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 11:35 A.M. with Registered Nurse (RN) #215 verified the light did not light up outside the room of Residents #09 and #18 and did not transmit a signal to the pagers carried by the staff. 2. Review of the medical record for Resident #16 revealed an admission date of 12/07/20. Diagnoses included chronic obstructive pulmonary disease, dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and non-st elevation (NSTEMI) myocardial infarction. Review of the quarterly MDS assessment revealed the resident had intact cognition and required supervision for bed mobility, transfers, and ambulation. Observation on 06/28/21 at 2:20 P.M. revealed Resident #16's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 2:20 P.M. with State Tested Nursing Aide (STNA) #240 verified the light did not come on outside the door nor did not transmit a signal to the pagers carried by the staff. Further interview with STNA #240 revealed the call light cord was not plugged into the wall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 5 of 5