Inspection·March 21, 2024

F 0645 Diagnoses for Resident #53 included dementia, bipolar disorder and depression. Level of Harm - Minimal harm or potential for actual harm Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and was receiving medications Olanzapine 2.5 mg two times a day for bipolar disorder, Divalproex sodium 125 mg for bipolar disorder and Citalopram hydrobromide 10 mg for depression. Residents Affected - Few Review of Resident #53 PASARR , dated 02/02/22, did not include the diagnoses of bipolar disorder and dementia. Interview on 03/20/24 at 2:30 P.M., the Administrator verified Resident #53 PASARR, dated 02/02/22 was inaccurate as it did not include the resident's diagnoses of bipolar disorder and dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 2 of 4 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 03/21/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facilities policy review, the facility failed to follow hand sanitation infection control practices during meal tray delivery. This had the potential to affect seven rooms of residents (Residents in rooms #204, #205, #209, #210, #105, #106 and #110). The facility total census was 64. Residents Affected - Some Findings include: Observation on 03/20/24 during lunch meal tray delivery, between 11:40 A.M. and 11:54 A.M., revealed State Tested Nurse Aide, (STNA) # 118 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #118 hands touched resident personal items on the overbed table to make room for the meal tray. The STNA #118 removed lids from the bowls of foods, touched the surface of the overbed table and touched the surface of the resident bed. STNA #118 exited Resident room [ROOM NUMBER] room past a wall mounted hand sanitizer dispensing station and a handwashing sink without sanitizing her hands. STNA #118 returned to the food delivery cart, touched the cart surface, touched her hair and delivered Resident room [ROOM NUMBER] meal tray. STNA #118 was observed to remove resident personal items from the overbed table, remove food container lids and touch the overbed table surface. STNA #118 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands. Observation on 03/20/24 between 11:40 A.M. and 11:54 A.M., revealed STNA #107 entered Resident Rooms #209, arranged personal items on the bedside stand, removed food bowl lids and touched the bed surface. STNA #107 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands. STNA #107 obtained and delivered Resident room [ROOM NUMBER] meal tray without performing hand sanitation between Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] meal tray deliveries. Observation on 03/20/24 during lunch meal tray delivery, between 11:50 A.M. and 12:01 P.M., revealed STNA #170 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #170 was observed to remove personal items from the overbed table, remove food bowl lids, assisted resident positioning, and touched the bed linens. The STNA #170 exited the room without hand sanitation, including washing or use of hand sanitizer. STNA #170 obtained Resident room [ROOM NUMBER] meal tray and delivered the meal tray. STNA #170 touched personal resident objects on the overbed table. STNA #170 did not perform hand sanitizing when leaving the room. STNA #170 obtained and delivered Resident room [ROOM NUMBER] meal tray with hand sanitizing from meal tray delivery of Resident room [ROOM NUMBER]. Interview on 03/20/24 at 11:48 A.M., STNA #118 verified she had not performed hand sanitation between meal tray delivery of Resident Rooms #204 and Resident room [ROOM NUMBER]. STNA #118 stated hand sanitation should be performed between every meal tray delivery. STNA #118 verified there were hand washing sinks and wall mounted hand sanitizing solution dispensers in every resident room. Interview on 03/20/24 at 11:49 A.M., STNA #107 verified she had not performed hand sanitation between meal deliveries of Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #107 stated sometimes the nurse aides forget to perform hand sanitizing between each meal tray delivery. Interview on 03/20/24 at 12:12 P.M., STNA #170 verified she had not performed hand sanitizing between meal tray delivery between Resident Rooms #105, Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #170 stated she was unsure how often hand sanitation should occur between meal tray (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 3 of 4 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 03/21/2024 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 0880 deliveries. Level of Harm - Minimal harm or potential for actual harm Interview on 03/21/24 at 10:39 A.M. the Director of Nursing, (DON) verified hand sanitizing should occur after handling a resident's belongings. The DON verified hand sanitizer solution and hand washing sinks were in each resident room for staff to perform hand sanitizing after meal tray delivery and prior to delivery of the next resident's meal delivery. Residents Affected - Some Review of the facility policy, titled, Infection Control Hand Hygiene, undated, revealed hand hygiene is in reference to utilization of alcohol-based products and or hand washing with soap and water. Use of hand hygiene is required before and after every resident contact including touching a resident, handling the resident's belongings, and after touching the face or hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366143 If continuation sheet Page 4 of 4